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HEMATOLOGICAL  ATLAS 

■ WITH    A 

DESCRIPTION   OF  THE  TECHNIC 

OF 

BLOOD     EXAMINATION 

BY        '        / 
V 

Priv.  Doz.  Dr.  Karl  Schleip 

Scientific  Assistant  in  the  Medical  Clinic  University  of  Freiburg  i/  B. 


ENGLISH   ADAPTATION   OF  TEXT 

BY 

Frederic  E.  Sondern,  M.D. 

Professor  of  Clinical  Pathology  New  York  Post-Graduate  Medical  School  and  Hospital. 
Director  of  Clinical  Laboratory  New  York  Lying-in  Hospital 


Witt)  71  Colorcb  aUuStrationsf 


REVISED  AND  IMPROVED  EDITION 


NEW   YORK. 

REBMAN    COMPANY 


mo 


Copyright,    1920,  nv 

BEBMAN    COMPANY 

New  York 


Printed  in  America 


A 


PREFACE  TO  THE  ENGLISH  EDITION 

The  paucity  of  good  pictures  illustrating  the 
changes  in  the  microscopic  appearance  of  the  blood 
which  have  become  apparent  by  the  use  of  panoptic 
staining  methods  is  e\'ident  to  the  teacher  of  Clinical 
Hematology.  To  this  fact  noted  by  the  author,  and 
to  the  opportunities  offered  him  by  the  hematological 

^  material  available  at  the  Medical  CUnic  of  the  Uni- 

versify  of  Freiburg,  this  Atlas  owes  its  origin.  An 
accurate  picture  of  characteristic  changes  is  often 
better  than  a  detailed  description  or  an  imperfect 
specimen. 

The  object  of  the  Atlas  is  not  only  to  assist  in 
teaching  the  subject  but  also  to  serve  as  a  guide  for 
the  private  study  of  the  clinician;  and  the  brief  diag- 

j'  nostic  points  and  explanatory  comments  may  be  of 

J\  value  in  this  connection.     In  the  nomenclature  of  the 

blood  cells  the  universally  used  terms  have  been  se- 

n  lected,  and  those  based  on  theories  not  yet  firmly 

'*        ■  established  have  been  avoided. 

A  sufficiently  detailed  technic  of  the  cHnical 
methods    used    in    blood    examination    has    been    in- 

^  eluded,  with  the  hope  of  enhancing  the  usefulness  of 

the  book,  and  the  compMcated  procedures  demanding 
extensive  apparatus  and  not  suited  to  the  use  of  the 
chnical  worker  have  been  omitted.  The  original 
illustrations  represent  specimens  stained  with  the 
Leish7nan  modification  of  the  Romanowsky  method, 

+-  and  uniform  magnifications  of  330  and  750  only  have 

0  been  used. 

S"  Few  slight  changes  have  been  made  in  the  Enghsh 

adaptation  of  the  text  where  these  seemed  indicated 
0  by  different  customs  and  racial  characteristics,  but 

+,  classifications,  nomenclature,  etc.,  are  strict  transla- 

C  tions  of  the  original. 

/  Frederic  E.  Sondern. 


or 

(5 


New  York  City. 


24971 


TABLE    OF    CONTENTS 

PAGE 

Preface   Iv 

Technic   of  Clinical  Methods  for  Examination   of 

THE  Blood   1 

Obtaining  the  Blood  and  Preparing  the  Dried  Films  1 

Estimation  of  the  Amount  of  Hemoglobin 2 

The  Sahli  Hemometer 2 

Counting  the  Blood  Corpuscles 3 

Diluting  Fluids   3 

Counting  the  Red  Corpuscles 4 

Counting  the  Leucocytes   6 

The  Differential  Count  of  Leucocytes 7 

Examination  of  Fresh  Blood   8 

Staining  the  Dried  Films 9 

Estimation  of  the  Specific  Gravity 10 

Formula  for  Blood  Stain   11 

Plate  I 

Fig.   1.  Development  of  White   and  Red  Blood   Cor- 
puscles      12 

Plate  II 

Fig.  2.  Normal  Blood   15 

Fresh   double    cover  -  glass    Specimen      unstained. 

Magn.  330    15 

Fig.  3.  The  same  specimen.    Magn.  750 15 

Plate  III. — Normal  Blood 

Fig.  4.   Stained  specimen.     Magn.  330 18 

Fig.  5.  Stained  specimen.     Magn.  750   18 

Plate  IV. — The  White  Corpuscles  of  the  Human 
Blood.    Leucocytes  of  the  Human  Blood.     Not 

including  Cells  of  the  Bone  Marrow    19 

Fig.   6.   Polymorphonuclear  Ncutrophiles.     Magn.  750  19 

Fig.  7.  Lymphocytes.     Magn.  750 20 

Fig.  8.  Transitional  Forms.     Magn.  750 20 

Plate  V 

Fig.  9.  Eosinophiles.     Magn.  750    22 

Fig.   10.  Basophilcs.     Magn.  750    22 

Fitr.   n.  Turk's  Irritation  Forms.     Magn.  750    23 

Iv 


Plate  VI  .   ^^^^ 

Fig.   12.  Two  Eosinophiles    and    Two    Transitionaib. 

Magii.  750 •  •  •   24. 

Fig.   13.  Two  Transitionals     and     two     Basophiles. 

Magn.  750   25 

Plate  VII 

Fig.  14.  Lymphocytes.     Magn.  750   25 

Fig.   15.  Degeneration  Forms  of  Leucocytes.     Magn. 
750    25 

Plate  VIII. — The  Varieties  of  Leucocytosis 26 

Fig.   16.   Neutrophilic    Leucocytosis.      Moist    Double 
Cover-glass  Specimen.     Magn.  750   26 

Plate  IX 

Fig.   17.  Neutrophilic    Leucocytosis.       Stained    Film. 

Magn.  330   27 

Plate  X. — Eosinophilic  Leucocytosis 28 

Fig.   18.  Eosinophilic    Leucocytosis.       Stained    Film. 
Magn.  330   28 

Plate  XI 

Fig.  19.  Neutrophilic    Leucocytosis.       Stained    Film. 

Magn.  750 ;  •  •    29 

Fig.  20.  Eosinophilic    Leucocytosis.       Stained    Film. 

Magn.  750    29 

Plate  XII 

Fig.  21.  Leucocytosis    in    a    Child.       Stained    Film. 
Magn.  330   ^^ 

Plate  XIII 

Fig.  22.  Blood  Changes  in  Diphtheria.     Stained  Film. 

Magn.  750    32 

Fig.  23.  Lymphocytosis.     Stained  Film.     Magn.  750.    32 

Plate  XIV. — The   Red    Corpuscles    of    the   Human 

Blood  and  the  Blood  Platelets 34 

Fig.  24.  Erythrocytes.     Magn.  750 34 

Fig.  25.  Nucleated  Red  Corpuscles   (Erythroblasts). 

Magn.  750    34 

Fig.  26.  Blood  Platelets.     Magn.  750    35 

Plate  XV. — The  Anemias 

Fig.  27.  Karyolytic  Forms  of  Erythroblasts.     Magn. 

750    •  •  •    ^"^ 

Fig.  28.  Polychromatophilic    Erythrocytes.      Stained 
Film.     Magn.  750   ^'^ 

V 


PAGE 

Plate  XVI. — Basophilic  Granulations    39 

Fig.  29.  Basophilic     Granulations.        Stained     Film. 

Magn.  750    39 

Fig.  30.  Lead  Poisoning.    Stained  Film.    Magn.  750 .  39 

Plate  XVII. — The  Secondary  Anemias 41 

Acute  Form    41 

Fig.  31.  Acute  Anemia.    Stained  Film.    Magn.  750..  41 

Secondary  Anemia,  Chronic  Form 41 

Fig.  32.   Chronic  Anemia.    Stained  Film.    Magn.  750.  41 

Plate  XVIII 

Fig.  33.   Chronic  Anemia.    Stained  Film.   Magn.  330 .    43 

Anemia  in  Children  having  Congenital  Syphilis 43 

Fig.  34.  Infantile  Hereditary  Syphilis.    Stained  Film. 
Magn.  750   44 

Plate  XIX. — Secondary    Anemias    45 

Fig.  35.   Chronic   Secondary   Anemia.      Fresh   Double 

Cover-glass  Specimen.     Magn.  750   45 

Fig.  36.  Crcnated  Erythrocytes.   Fresh  Double  Cover- 
glass  Specimen.     Magn.  750 45 

Plate  XX. — The  Primary  Anemias    47 

Fig.  37.  Pernicious    Anemia.      Fresh    Double    Cover- 
glass  Specimen.     Magn.  750 47 

Fig.  38.  Chlorosis.     Fresh  Double  Cover-glass  Speci- 
men.    Magn.  750   48 

Plate  XXI 

Fig.  39.  Chlorosis.     Stained  Film.     Magn.  750 49 

Fig.  40.   Chlorosis.     Stained  Film.     Magn.  750 49 

Plate  XXII. — Pernicious  Anemia    50 

Fig.  41.  Pernicious   Anemia.      Stained   Film.      Magn. 
750    51 

Plate  XXIII. — The  Lf.ukf.mias 52 

Fig.   42.  Myelogenous  Leukemia.   Fresh  Double  Cover- 
glass  Specimen.     Magn.  750    53 

Plate  XXIV 

Fig.   43.  Myelogenous  Leukemia.   Fresh  Double  Cover- 
glass  Specimen.     Magn.  750   54 

Fig.   44.  Myelogenous     Leukemia,       Stained    Film. 
Magn.  750    54 

Plate  XXV. — Chronic  Lymphatic  I^kukimia 56 

Fig.   45.  Chronic  Lymphatic  Leukemia.    Stained  Fihn. 
Magn.  330   57 

vi 


Plate  XXVI  pace 

Fig.  46.  Chronic  Lymphatic  Leukemia.    Fresh  Double 

Cover-glass  Specimen.     Magn.  750    58 

Fig.   47.  Chronic  Lymphatic  Leukemia.    Stained  Film. 

Magn.  750    58 

Plate  XXVII 

Fig.   48.   Chronic  Lymphatic  Leukemia.    Stained  Film. 
Magn.  330    59 

Plate  XXVIII 

Fig.   49.  Chronic  Lymphatic  Leukemia.    Stained  Film. 
Magn.  750   60 

Plate  XXIX. — Myelogenous  Leukemia    62 

Fig.     50.       Myelogenous    LeuTcemia.       Stained    Film. 
Magn.  330    64 

Plate  XXX 

Fig.     51.      Myelogenous    Leukemia.       Stained     Film. 
Magn.  750    65 

Plate  XXXI. — Myelogenous  Leukemia 67 

Fig.     52.      Myelogenous     Leukemia.       Stained    Film. 
Magn.  750    67 

PLATE  XXXII. — Myelogenous  Leukemia    69 

Fig.     53.      Myelogenous     Leukemia.       Stained     Film. 
Magn.  750   70 

PLATE  XXXIII. — Myelogenous  Leukemia 71 

Fig.     54.       Myelogenous    Leukemia.       Stained    Film. 
Magn.   750    72 

PLATE  XXXIV.— Myelogenous  Leukemia    73 

Fig.     55.      Myelogenous     Leukemia.       Stained    Film. 
Magn.  750   73 

PLATE  XXXV. — Myelogenous  Leukemia 75 

Fig.     56.      Myelogenous     Leukemia.       Stained     Film. 
Magn.  750    75 

PLATE  XXXVL— Acute  Leukemia 77 

Fig.  57.   Acute  Leukemia.   Stained  Film.    Magn.  750 . .  78 

PLATE  XXXVII 

Fig.  58.  Acute  Leukemia.     Fresh  Double  Cover-glass 

Specimen.     Magn.  750 80 

vii 


PAGE 

PLATE    XXXVIII.  —  Blood    Changes    Associated 

WITH    TUMOES    OF    THE    BoNE    MaHROW    ■. 81 

Carcinoma  of  the  Bone  Marrow 81 

Fig.   59.   Carcinoma   of   the   Bone   Marrow.      Stained 
Film.  Magn.  330 82 

PLATE  XXXIX.— Sarcoma  of  Bone  Marrow 84 

Fig.    60.   Sarcoma   of   Bone    Marrow.      Stained   Film. 
Magn.  7.50    85 

PLATE   XL. — Letikosarcomatosis    86 

Fig.    61.  Leukosarcomatosis.      Stained   Film.      Magn. 
750    87 

PLATE  XLI. — Blood  Parasites. 

Malarial     Parasites     and     Trypanosomes.        Tertian 
Malaria    88 

Fig.  62.  Endogenous  Development  of  Tertian   Para- 
site.    Magn.  750 .' 88 

Fig.  63.  Endogenous  Development  of  Quartan  Para- 
site.    Magn.  750 ■  ■  ■   89 

Fig.  64.  Endogenous  Development  of  Estivo-Autum- 
nal  Parasite.     Magn.  750 89 

PLATE  XLII. — Parasites  of  Tertian  Malaria 91 

Fig.  65.    Tertian  Malaria.    Fresh  Double  Cover-glass 

Specimen.     Magn.  750 91 

Fig.  66.  Tertian  Malaria.   Stained  Film.   Magn.  750.  .    92 

PLATE  XLIII 

Fig.  67.  Tertian  Malaria.     Stained  Specimen.     Magn. 

7.50    93 

Fig.  68.  Tertian  Malaria.   Stained  Film.   Magn.  750 .  .    94 

PLATE  XLIV 

Fig.  69.  Quartan  Malaria.    Stained  Film.    Magn.  750.    95 
Fig.    70.    Estivo-Autumnal    Malaria.      Stained    Film. 
Magn.  750    95 

PLATE   XLV.— Trypanosomiasis    96 

Fig.    71.     Human    Trypanosomiasis.      Stained    Film. 
Magn.  Approx.  1,000   97 

INDEX    98 


vni 


TECHNIC  OF  CLINICAL  METHODS 

FOR 

EXAMINATION  OF  THE  BLOOD 

Obtaining  the  Blood  and  Preparing  the  Dried  Films 

The  blood  is  usually  obtained  from  the  lobe  of  the 
ear  or  the  tip  of  the  finger  by  a  rapid  puncture  with 
one  of  the  various  blood  lancets  or  a  straight  Hage- 
dorn  needle  of  medium  size.  Experience  develops 
good  technic,  and  if  the  procedure  is  rapid  there  is 
practically  no  pain  or  subsequent  discomfort.  Previ- 
ous cleansing  of  the  skin  is  desirable,  for  by  thus 
softening  it  the  puncture  is  more  easily  made.  The 
blood  should  flow  slowly  of  its  own  accord  and  with- 
out pressure  on  the  immediately  surrounding  tissues. 
The  first  drop  of  blood  and  any  moisture  of  the  skin 
should  be  wiped  away  and  the  following  small  drop 
taken  up  on  the  surface  of  a  cover-glass  very  close  to 
its  edge.  A  slide,  wlaich  has  been  carefully  cleaned, 
is  held  by  the  left-hand  end  and  the  edge  of  the  cover- 
glass  placed  in  contact  with  it  at  the  other  end,  and 
inchned  to  the  right  until  the  blood  drop  also  touches 
the  shde  and  spreads  the  entire  width  of  the  cover- 
glass. 

Held  in  this  position  the  cover  is  now  rapidly 
pushed  over  the  surface  of  the  shde  toward  the  left 
hand,  the  drop  being  drawn  along  behind  it.  Any 
injury  to  or  distortion  of  the  corpuscles  is  avoided  by 
this  method,  as  no  pressure  is  used,  and  while  the 
resulting  spread  is  rather  thick  where  begun,  it  is 
quite  thin  and  uniform  toward  the  middle  and  left 
end  of  the  specimen. 

Several  precautions  should  be  observed.  The 
cover-glass  should  not  come  in  contact  with  the  skin 

1 


while  it  is  being  charged  with  blood,  and  the  smaller 
the  amount  used,  the  better  the  resulting  fihn.  The 
cover-glass  used  for  spreading  must  have  an  absolutely 
smooth  edge,  otherwise  the  leucocytes  may  be  dis- 
tributed unevenly,  thus  jeopardizing  the  accuracy  of 
the  differential  count.  The  whole  procedure  should 
be  accomplished  as  quickly  as  possible  so  that  com- 
paratively little  time  elapses  between  the  appearance 
of  the  drop  of  blood  and  the  drying  of  the  prepared 
fihiis. 

Estimation  of  the  Amount  of  Hemoglobin 

In  the  apphcation  of  clinical  methods  in  blood 
examination,  several  procedures  and  appliances  for 
determining  the  amount  of  hemoglobin  must  be  con- 
sidered. There  are  numerous  good  methods,  but 
none  as  yet  without  some  disadvantage.  In  most 
of  the  chnical  methods  employed,  the  diluted  blood  is 
compared  with  some  artificially  colored  substance. 
In  the  Fleischl-Miescher  hemometer  this  substance 
consists  of  a  wedge-shaped  piece  of  stained  glass, 
while  in  the  Gowcr's  hemoglobinometer  a  glycerin 
jelly  stained  with  picro-carmin  is  used.  Both  of 
these  methods  are  trustworthy  and  universally  used, 
but  the  new  Sahli  hemometer  deserves  special 
mention. 

The  Sahli  Hemometer 

The  inference  is  reasonable  that  the  best  colori- 
metric  determination  can  be  made  by  comparing  the 
solution  to  be  tested  with  one  of  known  strength  con- 
taining the  identical  pigment.  While  a  solution  of 
hemoglobin  would  be  the  ideal  standard,  this  is  not 
feasible  on  account  of  its  rapid  deterioration.  Con- 
sequently, Sahli  employs  a  stable  hemoglobin  deriv- 
ative as  a  standard,  and  converts  the  blood  to  be 
examined  into  the  same  derivative  before  the  deter- 
mination is  made.  The  principle  is  as  follows:  One 
part  of  blood  is  mixed  with  ten  parts  of  decinormal 
hydrochloric  acid  in  a  graduated  tube,  with  the  result 


that  an  acid  heniatin  is  obtained,  quite  constant  in 
color  and  composition.  This  dark  brown  fluid 
dikitcs  to  a  clear  yellow  with  water  and  is  well 
adapted  to  colorimetric  estimation.  The  standard 
solution  is  sealed  in  a  comparison  tube  of  exactly  the 
same  caliber  and  coiTesponds  to  a  1  per  cent,  solution 
of  normal  blood. 

To  apply  the  test,  the  graduated  tube  is  filled  with 
decinormal  hydrochloric  acid  to  the  10  per  cent, 
point,  to  which  20  c.mm.  of  blood  obtained  with  the 
capillary  pipette  is  added,  and  the  whole  carefully 
shaken.  As  soon  as  the  mixture  assumes  a  clear 
dark  brown  color,  water  is  added  drop  by  drop  mitil 
the  tint  corresponds  to  that  of  the  standard  tube. 
The  percentage  of  hemoglobin  is  read  from  the  point 
of  the  scale  corresponding  to  the  height  of  the  solu- 
tion. 

Counting  the  Blood  Corpuscles 

It  is  very  essential  that  the  blood  used  for  this  pur- 
pose be  taken  as  quickly  after  the  puncture  as  pos- 
sible with  accurate  technic,  in  order  to  avoid  sources 
of  considerable  error.  The  Thoma-Zeiss  counting 
chamber  can  be  recommended  for  the  separate  esti- 
mation of  red  cells  and  leucocytes,  but  for  greater 
convenience  and  accuracy  in  the  leucocyte  count  or 
when  leucocji:es  and  red  cells  are  to  be  counted  in 
the  same  preparation,  the  chambers  ruled  according 
to  Zappert  or  Tiirk  are  preferable. 

Diluting  Fluids 

In  order  to  count  the  red  corpuscles  it  is  necessary 
to  dilute  the  blood  with  a  fluid  which  will  prevent 
coagulation  and  cause  no  change  in  the  cellular  ele- 
ments.    One  of  the  following  may  be  used: 

Hay  em's  Solution: 

GRAM 

Bichloride  of  Mercury 0.5 

Sulphate  of  Sodium    5.0 

Chloride  of  Sodium    1.0 

Distilled  Water    200.0 

3 


Toisson's  Solution: 

Methyl  Violet  5  B 0.025 

Chloride   of   Sodium 1.0 

Sulphate  of  Sodium 8.0 

Glycerin    30.0 

Distilled  Water 160.0 

For  the  purpose  of  counting  the  leucocytes  a  dilut- 
ing fluid  is  required  which  lakes  the  red  corpuscles 
and  not  only  preserves  the  white  ceUs  but  also  makes 
their  nuclei  more  distinct.  This  is  accomphshed  by 
the  use  of  0.3  to  0.6  per  cent,  solution  of  glacial  acetic 
acid  to  which  a  few  drops  of  concentrated  aqueous 
solution  of  gentian  violet  may  be  added  to  stain  the 
nuclei. 

Counting  the  Red  Corpuscles 

The  Thoma-Zeiss  hemocytometer  consists  of  the 
following: 

1.  The  Mixing  Pipette  is  a  graduated  thick-walled 
capillary  tube,  pointed  at  one  end  and  dilated  into  a 
bulb  at  the  other,  with  a  short  tube  at  the  opposite 
pole  of  the  bulb  to  which  the  rubber  aspirating  tube 
is  attached.  The  bulb  contains  a  small  glass  ball  to 
facilitate  the  mixing.  The  capillary  tube  bears  the 
graduations  0.5  and  1.0  and  the  upper  end  of  the 
bulb  is  marked  101,  indicating  that  the  capacity  of 
the  bulb  is  100  times  that  of  the  capillary  tube. 

2.  The  Counting  Chamber  consists  of  a  hea\y  glass 
slide  on  which  a  square  glass  plate,  with  a  circular 
opening  1  cm.  in  diameter,  is  cemented.  A  circular 
glass  disk  8  mm.  in  diameter  is  cemented  in  the  center 
of  this  opening  in  such  a  way  that  a  ditch  separates 
the  two,  the  slide  forming  its  floor.  The  surface  of 
the  central  disk  is  exactly  0.1  mm.  lower  than  the 
level  of  the  outer  glass  plate  and  forms  the  floor  of  the 
counting  chaml)er.  Its  center  is  ruled  in  such  a  way 
that  400  small  squares  are  formed  each  having  an 
area  of  Hoo  sq.  mm.  An  extra  line  is  ruled  through 
each  fifth  row  of  squares,  as  shown  in  the  accompany- 

4 


ing  illustration,  to  facilitate  the  counting.    The  upper 
limit  of  the  chamber  is  formed  by  a  superimposed 
absolutely  plane  cover- 
glass. 

The  red  cell  count  is 
made  as  follows: 

After  the  puncture, 
made  in  the  usual  way, 
a  rather  large  drop  of 
blood  is  allowed  to  col- 
lect, and  this  is  rapidly  - 
drawn  into  the  pipette 
to  the  mark  1.0.  Aiter 
wiping  the  point,  it  is 

plunged  into  a  bottle  containing  the  diluting  fluid. 
Wliile  this  is  being  drawn  into  the  bulb  the  pipette 
should  be  twirled  between  the  fingers  to  mix  the 
blood  and  diluting  fluid.  AVhen  the  mark  101  is 
reached,  aspiration  is  stopped,  the  rubber  tube  re- 
moved, and  with  the  thumb  on  the  point  and  the 
middle  finger  closing  the  other  end,  the  whole  gently 
shaken.  Some  experience  is  necessary  before  perfect 
technic  is  acquired.  As  the  fluid  remaining  in  the 
cajjillary  tube  does  not  enter  into  the  mixture,  the 
bulb  now  contains  1  part  blood  and  99  parts  diluting 
fluid.  If  the  blood  has  been  drawn  to  the  mark  0.5 
the  dilution  is  1  in  200,  instead  of  1  in  100  as  above. 

The  rubber  tube  is  again  attached,  a  few  drops 
blown  out,  the  point  wiped  dry,  and  the  next  small 
drop  placed  in  the  center  of  the  scrupulously  clean 
counting  chamber,  over  which  the  pohshed  cover- 
glass  is  placed  with  some  pressure.  If  the  contact  is 
perfect,  as  it  must  be  if  accurate  results  are  desired, 
the  Newton's  rings  are  visible.  The  drop  used  must 
not  be  too  large  or  some  of  it  will  fill  the  ditch  and 
run  between  the  cover  and  the  outer  glass  disk.  In 
this  case  it  is  necessary  to  repeat  the  procedure  with  a 
smaller  drop. 

The  shde  is  now  left  undisturbed  for  about  five 

6 


minutes  to  allow  the  corpuscles  to  settle  on  the  bottom 
of  the  chamber.  The  counting  of  the  corpuscles  is 
best  done  with  a  magnification  of  about  300,  which 
presents  a  good  picture  of  the  network  of  squares. 
The  area  of  each  small  square  is  %oo  sq.  mm.,  and  the 
distance  between  the  floor  and  the  lower  surface  of 
the  cover  is  /4o  mm.,  consequently  each  square  repre- 
sents wffu  cu.  mm.  The  cells  in  a  large  number  of 
these  squares  are  now  counted,  including  those  which 
touch  or  overlap  the  upper  and  left-hand  boundary 
lines,  but  not  those  which  touch  or  overlap  the  lower 
and  right-hand  boundary  hnes.  With  proper  technic 
the  corpuscles  are  uniformly  distributed  and  counting 
those  in  100  small  squares  is  usually  sufficient.  If  a 
dilution  of  1:100  has  been  used,  the  calculation  will 
be  as  follows:  Supposing  1,450  corpuscles  were 
counted  in  100  small  squares,  each  square  will  average 
Tinr  corpuscles.  As  each  square  represents  a  height 
of  /4o  mm.  and  a  surface  of  /4oo  sq.  mm.,  each  cubic 
mm.  contains  10  X  400  =  4,000  times  as  many  cells. 
A  dilution  of  1 :100  having  been  used  the  blood  con- 
tains 100  times  as  many  cells  as  the  dilution.  There- 
fore the  formula  for  the  calculation  will  be, 

1,450  X  4,000  X  100 

=  1,450  X  4,000  =  5,800,000 


100 

red  corpuscles  in  1  cu.  mm.  of  blood. 

The  careful  cleaning  of  the  pipette  is  important, 
and  this  is  accomplished  by  putting  the  rubber  tube 
on  the  capillary  tube  end  of  the  pipette  and  drawing 
water  through  it.  This  is  followed  by  alcohol  and 
then  by  ether,  the  latter  being  allowed  to  run  out  first 
one  end  and  then  the  other  by  itself.  Air  is  then 
sucked  through  })y  mouth  or  asj)irator  until  the  in- 
terior is  dry.  The  counting  chamber  is  rinsed  in 
water  only. 

Counting  the  Leucocytes 

I'^or  the  enumeration  of  the  leucocytes,  large  bore 
pipettes  are  usually  employed,  with  a  resulting  dilu- 

G 


tion  of  1 :10  or  1 :20,  the  bulb  holding  but  10  times  as 
much  as  the  capillary  tube.  After  the  dilution  with 
the  acetic  acid  solution  has  been  made,  the  procedure 
is  the  same  as  in  counting  red  corpuscles. 

For  reasons  mentioned,  a  chamber  with  Zappert 
ruling  should  preferably  be  used  for  leucocytes,  as  it 
admits  of  counting  2,000  small  squares  in  one  speci- 
men. Supposing  the  dilution  was  1:10,  and  2,000 
squares    were    counted,    the    calculation    would    be 

X  X  4.000  X  10  ^  X  ^  ^„ 
2,000 

Extreme  care  and  accuracy  are  absolutely  essential 
in  every  blood  cell  count,  if  the  result  is  to  be  correct. 
Beginners  cannot  possibly  avoid  all  sources  of  error, 
and  practice  is  undoubtedly  necessary  before  a  proper 
and  uniform  technic  can  be  acquired. 

The  Differential  Count  of  Leucocytes 

Owing  to  the  development  in  the  knowledge  of 
blood  changes  in  disease,  a  proper  estimation  of  the 
condition  of  the  blood  usually  demands  information 
concerning  the  relative  percentage,  or  the  absolute 
number,  of  the  different  varieties  of  leucocytes  pres- 
ent, in  addition  to  the  total  leucocyte  count.  Fluc- 
tuations in  the  quantitative  relation  of  the  various 
forms  are  not  uncommon  and  may  present  a  differ- 
ential count  suggestive  or  pathognomonic  of  a  given 
disease.  In  other  cases,  valuable  prognostic  data  may 
be  derived  from  the  differential  count. 

Evenly  spread  and  stained  blood  fihns  are  em- 
ployed for  the  count,  and  the  use  of  a  mechanical 
stage  is  desirable.  The  easiest  method  of  tally  is  to 
have  another  person  note  the  cells  as  called,  but  in 
the  absence  of  such  help  the  number  of  neutrophiles 
may  be  kept  in  mind  and  the  other  varieties  noted  on 
paper.  With  a  little  practice  every  one  usually  de- 
vises a  convenient  scheme.  A  minimum  of  300,  but 
preferably  500,  cells  should  be  counted  in  order  to 

7 


secure  approximately  reliable  results.  The  relative 
or  percentage  value  of  each  variety  is  then  figured, 
and  the  absolute  count  should  also  be  determined, 
by  applying  the  percentages  to  the  total  leucocyte 
count  made  by  means  of  the  counting  chamber. 

^Vhile  making  the  differential  count,  the  character 
of  the  red  blood  cells,  the  approximate  number  of 
blood  platelets,  and  the  presence  or  absence  of 
nucleated  red  cells  or  plasmodia  of  malaria  should 
also  be  noted. 

Examination  of  Fresh  Blood 

The  examination  of  fresh  blood  in  its  moist  un- 
stained state  is  frequently  conducted  in  an  improper 
manner.  When  a  drop  of  blood  is  examined  between 
slide  and  cover-glass,  evaporation  and  mechanical 
injury  are  apt  to  occur,  and  the  degree  of  poikilocy- 
tosis,  for  example,  cannot  be  properly  estimated. 
Under  these  conditions  the  use  of  an  oil-immersion 
objective  is  also  difficult,  as  the  cover-glass  may  float 
on  the  layer  of  blood. 

The  following  procedure  is  recommended:  A  ring 
of  cedar  oil  is  applied  around  the  edge  of  the  concave 
depression  in  a  hanging  drop  slide.  A  perfectly  clean 
square  cover-glass  is  prepared  and  a  likewise  clean 
small  piece  of  cover-glass  about  4  mm.  in  diameter  is 
placed  on  the  center  of  it.  The  large  bore  Thoma- 
Zeiss  pipette  is  then  filled  with  fresh  blood  and 
diluted  in  proportion  of  1:10  with  physiological  salt 
solution.  After  mixing  and  blowing  out  a  few  drops, 
a  little  of  the  diluted  blood  is  allowed  to  run  between 
the  two  cover-glasses,  as  prepared,  and  the  inverted 
concave  slide  placed  in  such  a  position  that  the  oil 
ring  is  in  perfect  contact  with  the  larger  cover-glass. 
The  specimen  is  then  turned  right  side  up  and  has 
the  appearance  as  illustrated. 

The  completed  specimen  of  diluted  blood  is  thus 
prepared  in  a  way  which  ^certainly  prevents  evapora- 
tion and  mechanical  injury.     The  capillary  layer  is 

8 


preferable  to  the  hanging  drop,  and  the  dilution  is 
employed,  as  it  permits  a  more  careful  study  of  the 
shape  of  individual  corpuscles  than  is  possible  when 
undiluted  blood  is  examined.  The  specimens  may 
be  examined  with  a  low  or  high  power,  and  if  kept 
warm  will  show  all  the  characteristics  even  after  the 
lapse  of  hours.     The  excellent  results  obtained  by 


a-e 


Counting  chamber.  Cross  section,  a.  Object  slide,  b.  Counting  plate. 
c.  Restangular  plates  to  support  cover-glass  e.xactly  0.1  mm.  above 
the  counting  plate,    d.  Special  thick  cover-glass. 

means  of  this  method  are  well  shown  in  Table  II, 
Figure  3.  Staining  fluids  may  be  added  to  the  dilut- 
ing solution  for  the  easier  recognition  of  leucocytes, 
five  drops  of  an  aqueous  solution  of  gentian  violet 
to  each  10  c.c.  of  salt  solution  being  recommended. 

Staining  the  Dried  Films 
The  Romanowsky  method,  or  one  of  its  numerous 
modifications,  is  in  almost  universal  use  at  present 
for  staining  dried  blood  spreads.  For  some  years 
the  author  has  used  the  Leishman*  modification 
almost  exclusively.  This  is  an  eosinate  of  methylene 
blue  dissolved  in  methyl  alcohol,  which  fixes  and 
stains  the  specimens  simultaneously.  The  Leishman 
is  a  panoptic  stain,  and  preferable  on  account  of  the 
simplicity  of  the  procedure.  It  is  used  as  follows: 
The  air-dried  blood  fihn,  without  previous  fixation, 
is  covered  with  about  ten  drops  of  staining  fluid. 
After  about  thirty  seconds,  double  this  amount  of 
distilled  water  is  added  to  and  mixed  with  the  stain. 
Five  minutes  later  the  mixture  is  washed  off  with 
water,  and  the  shde  dried  between  hntless  blotters. 

*  TV  B  Leishman.  A  Simple  and  Rapid  Method  of  producing  Ro- 
manowsky Staining  in  Malaria  and  other  Blood  Films.  British  Med. 
Journ. 

9 


If  the  specimen  is  overstained,  the  erythrocytes  have 
a  deep  red  or  greenish  tint.  This  can  be  remedied 
by  allowing  a  few  drops  of  distilled  water  to  remain 
on  the  shde  for  one  or  two  minutes,  after  which  it  is 
washed  and  dried  as  before.  The  entire  procedure 
of  spreading  the  blood,  drying,  staining  and  placing 
the  specimen  under  the  microscope  should  not  con- 
sume more  than  seven  or  eight  minutes.  Only  one 
reagent  and  a  little  distilled  water  are  needed  for  the 
staining.  The  results  of  the  method  are  shown  on 
the  following  pages,  and  particular  attention  is  called 
to  Plates  IV,  V  and  XV. 

The  stained  specimen  can  now  be  studied  with  a 
low  power  or  with  an  immersion  lens,  a  permanent 
mounting  in  balsam  being  unnecessary.  If  balsam 
is  used,  it  is  well  to  remember  that  an  acid  balsam 
decolorizes  the  specimen  after  a  time.  The  cedar  oil 
used  on  unmounted  specimens  can  be  removed  with 
xylol  without  injury  to  the  blood  film. 

Estimation  of  the  Specific  Gravity 

A  knowledge  of  the  concentration  of  the  blood  is  of 
considerable  importance  in  a  number  of  diseases. 
The  experienced  observer  will  immediately  note  de- 
cided changes  in  this  respect  by  the  appearance  of 
the  blood,  which  observation  is  sufficiently  accurate 
to  determine  the  degree  of  dilution  best  suited  to  the 
general  blood  examination  about  to  be  made. 

The  Schmalz  method  of  determining  the  specific 
gravity  by  means  of  a  capillary  pycnometer  is  useful 
and  accurate,  but  requires  experience.  A  glass  tube 
about  10  cm.  long,  constricted  at  both  ends  and  hold- 
ing 0.2  CO.  of  fluid,  is  weighed  empty  on  an  accurate 
balance  sensitive  to  0.1  mg.  It  is  then  filled  with 
distilled  water  and  again  weighed.  The  diff'erence 
represents  the  weight  of  the  water  held  by  the  tube. 
After  thorough  drying  the  tube  is  filled  with  blood 
and  the  outer  surface  carefully  cleaned.  The  net 
weight  of  the  l)l()od  divided  by  the  weight  of  the  water 

10 


will  indicate  the  specific  gravity  of  the  former.  The 
normal  specific  gravity  of  the  blood  is  variously 
stated,  but  averages  1052  to  1058  in  men  and  1048 
to  1055  in  women. 

Formula  for  Blood  Stain 

A  formula  for  a  polychromatic  blood  stain  was 
purposely  omitted  from  the  ATLAS  on  account  of 
the  difficulty  attending  its  proper  manufacture.  Pre- 
pared stains  ready  for  use  can  be  obtained  in  any 
of  the  shops  dealing  in  microscopical  goods. 

Wright's  Stain  is  used  in  the  same  manner  as  that 
devised  by  Leishman;  the  results  obtained  are  the 
same  and  the  advantage  hes  in  its  easier  preparation. 

Dissolve  Sodium  bicarb.,  0.5  gram,  in  distilled 
water  100  c.c.  and  then  add  Methylene  blue  rectified 
1  gram.  Place  in  a  steam  steriUzer  for  one  hour. 
When  cold,  add  about  500  c.c.  of  a  1:1000  solution 
of  Eosin  Griibler  w.g.,  or  enough  to  make  the  mix- 
ture purple  with  a  metaUic  scum  on  the  surface.  The 
precipitate  is  collected  on  a  filter  and  allowed  to  dry. 
When  thoroughly  dry  dissolve  this  precipitate  0.5 
gram,  in  Methyl  alcohol  Merck  reagent  10  J  c.c.  which 
makes  the  stain.  Keep  balance  of  the  precipitate  for 
subsequent  use. 


11 


PLATE    I 

The  Development  of  White  and  Red  Blood 
Corpuscles 

The  normal  and  pathological  cells  of  the  human 
hlood  all  probably  originate  in  the  bone  marrow,  with 
the  exception  of  the  lymphocytes.  Of  these  a  small 
number  are  derived  from  the  bone  marrow,  but  by 
far  the  larger  number  come  from  the  lymph  glands. 

A  previous  study  of  the  mamier  of  development  of 
the  different  cells,  according  to  the  generally  accepted 
theory,  will  lead  to  a  better  understanding  of  the 
chnically  important  changes  in  the  blood,  the  signifi- 
cance of  individual  cells  and  the  relations  they  bear 
to  one  another. 

All  human  blood  cells  can  easily  be  traced  to  one 
parent  form  ( 1 ) .  An  unbroken  series  of  cells  repre- 
senting successive  stages  of  development  are  found 
between  this  parent  form  and  the  normal  cells  of  the 
blood.  The  cells  closest  to  the  parent  form  show 
different  characteristics  at  an  early  period  by  assum- 
ing either  a  basophihc  (2)  or  a  neutrophihc  (3) 
protoplasm.  Subsequently,  these  cells  develop  into 
other  forms  ( 4  and  5 ) ,  constituting,  on  the  one  hand, 
a  transition  into  the  mature  neutrophilic  granular 
cells  of  the  bone  marrow  (6),  the  so-called  neutro- 
philic myelocytes,  and,  on  the  other  hand,  pass,  by 
further  intermediate  stages,  into  lymphocytes  (13) 
and  transitional  forms  (15).  The  term  "transitional 
form"  is  derived  from  the  older  interpretation  of  this 
cell  as  a  preliminary  stage  of  the  polymorphonuclear 
neutrophile,  or  as  an  intermediate  stage  between  that 
cell  and  the  neutrophilic  myelocyte.     This  view  is 

12 


Plate  I.     Fig.  1 


\i 


I't 


scarcely  justified  at  the  present  state  of  our  knowl- 
edge and  it  is  probable  that  the  transitional  form  also 
represents  a  terminal  cellular  type  incapable  of  fur- 
ther development. 

The  large  cell  with  homogeneous  basophihc  proto- 
plasm   (2)    also  gives  rise,  by  way  of  intermediate 
stages,  to  the  basophihc  myelocj'te  (8),  which  in  turn 
is  transformed  into  the  basophile  (11).     The  eosino- 
phile  (12)  may  be  derived,  by  way  of  the  eosinophilic 
myelocyte   (9),  from  the  prehminary  stages  of  the 
basophihc  myelocji;e.    A  close  relationship  probably 
exists  between   the  basophihc   and   the   eosinophihc 
myelocyte,  notwithstanding  their  dissimilar  staining 
quahties,  as  intermediate  stages  between  these  two 
cells  are  not  infrequently  encoimtered  in  leukemic 
blood.     Basophiles  are  invariably  found  increased  in 
cases  of  relative  eosinophiha,  and  the  association  of 
these  mature  cells  is  a  common  chnical  phenomenon. 
The  neutrophihc  leucocyte  (10)  is  derived  from  the 
neutrophihc  myelocji;e   (6)  in  the  same  way  as  the 
normal  eosinophil  and  basophile  (12  and  11)  develop 
from  the  corresponding  eosinophihc  myelocyte    (9) 
and  the  basophihc  myelocyte  ( 8) .    The  rare  irritation 
form  of  Tiirk   (14)   is  at  present  interpreted  as  a 
lymphocyte,  the  further  development  of  which  is  due 
to  a  pathological  stimulus,  and  not  as  a  prehminary 
stage  of  the  mature  lymphocyte    (13),  as  formerly 
beheved. 

The  erythrocytes  can  also  be  traced,  by  direct 
transition,  to  the  parent  cell;  the  large  mononuclear 
cell  with  homogeneous  basophihc  protoplasm  (2) 
being  a  forerunner  of  the  megaloblast  (16).  The 
megaloblast  in  its  early  stage  may  have  a  voluminous 
basophihc  cell  body  and  a  relatively  large  nucleus 
and,  occurring  in  the  peripheral  circulation,  is  often 
distinguished  with  difficulty  from  the  Tiirk  irritation 
form  (see  Fig.  41).  As  the  result  of  the  further 
development  of  the  megaloblast,  the  normoblast  is 
formed,  and  subsequently  the  erythrocyte  (17). 


13 


Plate  I  represents  a  genealogical  scheme  of  devel- 
opment, including  the  chief  types  only.  In  the  desig- 
nation of  cells  the  suggestion  of  Grawitz  is  recom- 
mended, that  for  the  present  the  terms  having  definite 
significance,  such  as  "myelocyte,"  be  adhered  to,  with 
the  additional  characteristic  attached,  for  example: 
neutrophihc  myelocyte,  eosinophilic  myelocyte,  etc., 
rather  than  the  arbitrary  nomenclature  suggested  by 
different  authors. 

In  the  development  of  all  blood  corpuscles,  the 
following  chief  forms  must  be  considered: 

1.  Large  mononuclear  cell  with  pale  homogeneous 
cell  body  =  parent  cell. 

2.  Large  mononuclear  basophihc  cell. 

3.  Large  mononuclear  neutrophilic  cell. 

4.  Mononuclear  basophihc  cell  in  which  there  are 
few  neutrophihc  granules. 

5.  Mononuclear  neutrophihc  cell  in  which  there 
are  few  neutrophihc  granules. 

6.  Mononuclear  cell  with  dense  neutrophihc  gran- 
ulation =  neutrojjhihc  myelocyte. 

7.  Mononuclear    basophihc    cell    with    beginning 
basophihc  granulation. 

8.  Mononuclear  cell  with  basophilic  granulation 
=  basophihc  myelocyte. 

9.  Mononuclear  cell  with   eosinopliihc  granula- 
tion =  eosinophilic  myelocyte. 

10.  Neutrophile. 

11.  Basophile. 

12.  Eosinophile. 

13.  Lymphocyte. 

14.  Tiirk  irritation  form. 

15.  Transitional  form. 
IG.  Erythroblast. 

17.  Erythrocyte. 


14 


Plate  II.     Figs.  2,  3 


PLATE    II 

NORMAL  15L00D 


The  blood  of  healthy  individuals  presents  certain 
physiological  variations  within  comparatively  narrow 
limits.  The  average  composition  is  approximately  as 
follows : 

Children  >4  to  15  years:  Hemoglobin,  70  to  80  per  cent.;  red 
cells,  4,900,000;  leucocytes,  9,000  in  1  c.  mm. 

Men:  Hemoglobin,  90  to  100  per  cent.;  red  cells,  5,100,000; 
leucocytes,  7,500  in  1  c.  mm. 

Women:  Hemoglobin,  85  to  95  per  cent.;  red  cells,  4,500,000 
to  5,000,000;  leucocytes,  7,500  in  1  c.  mm. 

Healthy  Man,  32  years  old:  Hemoglobin,  120  per  cent.;  red 
cells.  5,600,000;  leucocytes,  7,800. 

Figure  2.— Fresh   Double  Cover-Glass   Specimen 
Unstained.    Magnification  330 

The  pale  yellow  color  of  the  erythrocytes  is  the 
characteristic  normal  hemoglobin  tint.  The  cells  are 
uniform  in  size,  some  appearing  cup  shaped  on  ac- 
count of  their  position.  The  detailed  structure  is 
more  apparent  when  a  higher  power  is  used. 

Figure  3.— The   Same  Specimen.     Magnification 

750 

Normal  red  blood  corpuscles  appear  cup-shaped 
with  thickened  walls.  This  appearance  is  only  noted 
as  long  as  injurious  influences  are  excluded,  such  as 
evaporation,  drying  from  any  cause,  hypertonia, 
isotonia,  cold  or  heat,  which  cannot  always  be  pre- 
vented, even  by  experienced  workers.    This  cup  shape 

15 


is  best  noted  in  the  corpuscles  lying  by  themselves; 
the  convexity  is  apparent,  and  on  the  opposite  side 
the  concavity  of  the  cup  can  be  seen,  its  rounded 
margin  merging  into  the  outer  wall  of  the  blood  cell. 

The  lateral  aspect  of  the  red  corpuscle  is  well 
curved  and  sausage  shaped,  on  the  concave  side  of 
which  there  is  a  hght  transparent  wall  with  convex 
margin.  If  the  corpuscle  hes  so  that  the  open  end 
of  the  cup  can  be  looked  into,  the  appearance  is  that 
of  a  circle  with  a  sharply  defined,  lighter  colored 
center.  This  light  center  corresponds  to  the  trans- 
parent crest  at  the  floor  of  the  cup,  and  the  darker 
colored  outer  ring  to  the  relatively  much  thicker  wall 
of  the  cup. 

Seen  from  above  the  corpuscle  appears  globular, 
and  the  cup -shaped  form  can  only  be  noted  on 
focusing  a  lower  level.  Most  of  the  red  corpuscles 
in  the  double  cover-glass  specimen  present  this 
appearance. 

Deviations  from  this  fundamental  form  are  noted, 
but  these  have  as  yet  assumed  no  pathological  sig- 
nificance. The  cup  shape  may  be  more  or  less  pro- 
nounced and  the  opening  may  vary  in  width. 

The  erythrocyte  is  frequently  seen  in  the  form  of  a 
biconcave  disk,  both  concavities  occupied  by  a  con- 
vex transparent  membrane.  This  appearance  is  ex- 
plained by  the  crest  of  the  bell  having  become  in- 
dented by  contact  with  another  corpuscle.  These 
indentations  are  rarely  seen  in  the  lateral  wall  of  the 
corpuscle.  AVlien  the  red  corpuscles  are  close  to- 
gether the  so-called  rouleaux  formation  occurs  as  the 
result  of  crowding,  the  concave  portion  of  one  cor- 
puscle slipping  over  the  convex  portion  of  the  adja- 
cent one.  In  this  condition  the  actual  form  of  the 
corpuscles  cannot  be  made  out.  (See  Figs.  16,  35, 
37,  38,  42,  43,  46  and  51.)     {Weidenreich.) 

Three  leucocytes  are  also  seen  in  the  field;  the 
smallest,  with  a  round  nucleus  surrounded  by  a  nar- 
row rim  of  i^rotoplasm,  is  a  lymphocji;e.    The  larger 

16 


cell  on  the  left  with  polymorphonuclear  configuration 
and  dense  finely  granular  protoplasm  is  a  jjoly- 
morphonuclear  leucocyte.  The  cell  above  presents 
a  striking  appearance,  the  nucleus  consisting  of 
several  portions  connected  by  thin  nuclear  strands. 
The  protoplasm  is  filled  with  coarse,  round,  strongly 
refractive  granules,  some  lying  apparently  beyond 
the  cell  but  actually  within  protoplasmic  processes  of 
the  cell,  which  is  in  slight  ameboid  motion.  This 
cell  is  an  eosinophile  which  is  identified  in  the  fresh 
specimen  by  its  highly  refractive  coarse  granulation. 


17 


PLATE    III 

NORMAL   BLOOD 

Figure  4. — Stained  Specimen.     Magnification 

330 

[The  same  case.] 

All  the  erythrocytes  are  uniform  in  size  and,  on 
account  of  being  spread,  are  seen  as  flat  circular 
yellowish-red  disks,  the  cup  shape  not  being  apparent. 
While  some  seem  uniformly  pigmented,  the  majority 
have  a  lighter  colored  central  zone  and  a  darker 
periphery,  which  is  due  to  the  original  cup  shape  of 
the  corpuscle.  The  details  are  more  apparent  with 
the  use  of  a  higher  power. 

Figure  5. — Stained  Specimen.     Magnnification 

750 

[The  same  case.] 

The  appearance  of  the  erythrocytes  is  more  dis- 
tinct in  this  specimen.  The  depressed  center,  being 
a  thin  wall,  is  faintly  stained,  while  the  thicker  edge 
has  a  deeper  tone.  A  neutrophilic  leucocyte  and  two 
lymphocytes  of  different  size  are  also  seen  in  the  field. 


18 


Plate  III.      Figs.  4,  5 


Plate  IV.     Figs.  6,  7,  8 


PLATE    IV 

THE    WHITE    CORPUSCLES   OF   THE    HUMAN    BLOOD 

Leucocytes  of  the  Human  Blood 

Not  Including  Cells  of  the  Bone-Marrow 

The  number  of  leucocytes  in  1  c.  mm.  of  blood  in 
an  adult  is  approximately  7,500.  These  consist  of  a 
variety  of  different  forms,  which,  under  normal  cir- 
cumstances, are  present  in  a  definite  numerical  ratio 
to  one  another.  This  enumeration  is  known  as  the 
"Differential  Count  of  Leucocytes,"  and  the  follow- 
ing are  the  normal  varieties  and  figures : 

Polymorphonuclear    Neu- 

trophiles    65  to  70  per  cent,  or  4,900  to  5,300  in  1  c.mni. 

Lymphocytes    20  to  25  per  cent,  or  1.500  to  2,000  in  1  c.mni. 

Transitional  Forms 3  to     5  per  cent,  or     230  to     380  in  1  c.min. 

Eosinophiles 2  to     4  per  cent,  or      150  to      300  in  1  c.mm. 

Basophiles %  per  cent,  or  40  in  1  c.mm. 

Turk's  Irritation  Forms  rarely  occur. 

In  children  under  5  years  of  age,  the  lymphocyte  is 
the  predominating  cell,  and  the  polymorphonuclear 
neutrophiles  usually  amount  to  less  than  50  per  cent. 

Figure  6. — Polymorphonuclear  Neutrophiles, 
Magnification  750 

These  cells  are  usually  about  twice  the  size  of  an 
erythrocyte,  rarely  larger.  The  nucleus  is  character- 
ized by  its  polymorphous  configuration,  some  of  the 
portions  often  being  connected  by  thin  nuclear 
strands.  Apparently  separate  nuclear  segments  are 
occasionally  seen,  but  these  have  "underground" 
connection,  as  the  cells  are  never  polynuclear.     The 

19 


protoplasm  is  neutrophilic  and  shows  close  fine 
granulations  which  are  especially  apparent  in  cases 
of  leucocytosis,  but  are  occasionally  so  shght  that 
they'  cannot  be  brought  out  even  in  overstained 
specimens.  The  neutrophihc  quaUt^-  of  the  proto- 
plasm also  varies,  and  these  differences  are  probably 
due  to  different  ages  and  functions  of  the  cells,  rather 
than  to  any  fault  in  staining. 

Figvire  7. — Lymphocytes.     Magnification 
750 

The  cells  are  extremely  varied  in  size  and  some 
show  a  narrow,  others  a  broad  ring  of  protoplasm. 
The  majority  are  small,  little  larger  than  an  eryth- 
rocyte, but  very  large  forms,  four  or  five  times  the 
size  of  the  small  ones,  are  frequently  seen  in  children, 
and  occasionally  in  adults.  The  nucleus  is  usually 
round  and  sometimes  indented,  and  in  the  larger  forms 
it  is  oval  or  polygonal.  It  stains  deeply  in  the  small 
cells  and  rather  faintly  in  the  larger  ones  and  two  or 
more  nucleoli  may  become  visible.  The  protoplasm  is 
shghtly  basophihc, — more  so  in  the  small  cells  than 
in  the  large  ones, — and  occasionally  the  outer  zone 
stains  darker  than  that  close  to  the  nucleus.  The 
large  Ijinphocytes  may  present  angular  or  irregular 
outlines.  A  smaller  or  larger  nimiber  of  all  lympho- 
cytes show  acidophilic  granulation,  which  appears  as 
fine  particles  or  angular  granules.  This  is  noted  in 
every  specimen  and  has  no  pathological  significance 
as  yet. 

Figure  8. — ^Transitional  Forms.     Magnification 

750 

These  cells  are  invariably  larger  than  the  poly- 
morphonuclear neutrophiles  and  frequently  irregu- 
larly round  in  outline.  (The  irregular  outline  as  in 
the  case  of  the  large  lymphocytes  is  probably  referable 
to  adjacent  erythrocytes,  or  those  in  close  proximity.) 

20 


Compared  with  the  other  lymphocytes,  the  nucleus  is 
always  paler  and  poorer  in  chromatin.  It  is  usually 
horseshoe-shaped  or  multilobular,  rarely  round  and 
indented.  The  protoplasm  is  slightly  basophilic  and 
contains  more  or  less  marked  neutrophilic  granulation 
most  apparent  in  the  nuclear  indentations.  With 
these  characteristics  in  mind,  the  cells  are  easily  dif- 
ferentiated from  the  polymorphonuclear  neutrophiles. 


21 


PLATE    V 

Figure  9. — Eosinophiles.      Magnification  750 

These  are  very  striking  and  easily  identified  round 
cells  of  the  same  size  as  polymorphonuclear  neutro- 
philes,  rarely  larger  or  smaller.  They  frequently 
have  two  or  three  oblong  or  oval  nuclear  portions  con- 
nected by  thin  nuclear  strands,  which  are  occasionally 
unequal  in  size. 

The  protoplasm  is  faintly  basophihc  and  shows  a 
bright-red  coarse  granulation.  The  granules  are 
round,  varying  in  number,  and  may  be  arranged  in 
groups.  Some  cells  are  so  densely  filled  with  granules 
that  they  can  scarcely  be  distinguished. 

In  one  case  of  trichinosis,  the  author  found  a  cell 
containing  an  equal  number  of  eosinophilic  and 
basophilic  granules  (see  Fig.  9). 

Figure  10. — Basophiles.     Magnification  750 

These  cells  vary  in  appearance  and  are  about  the 
size  of  an  eosinophile.  They  occur  less  frequently, 
and  are  not  as  easily  recognized.  The  nucleus 
occupies  about  two-thirds  of  the  cell,  usually  pre- 
senting the  outline  of  a  clover-leaf  or  rosette,  rarely 
round  or  indented,  with  no  defined  margin.  The 
protoplasm  shows  a  fine  basophilic  or  eosinophilic 
network.  Round  coarse  granules  of  varied  size  are 
seen  at  the  points  of  intersection,  or  these  may  fill 
the  entire  cell  and  lie  on  the  nucleus.  The  granules 
take  a  deep  chromatin  stain  and  have  basic  properties. 
The  cells  are  occasionally  free  from  granules  and  then 
vacuoles  are  found  in  the  network. 

22 


I- 


Plate  V.     Figs.  9,  10,  11 


■■^.: 


n 


#      ^ 
&> 


Figure  11.— Tiirk's  Irritation  Forms. 
Magnification  750 

These  cells  are  only  found  in  pathological  blood 
after  leucocytoses  and  inflammatory  processes.  They 
resemble  the  large  lymphocytes  in  type,  have  a 
large  nucleus,  poor  in  chromatin  and  frequently  small 
nucleoli.  The  nucleus  is  not  always  in  the  center  of 
the  cell  and  is  surrounded  by  a  band  of  protoplasm 
which  varies  in  width  and  takes  a  dark  blue  stain. 
Vacuoles  may  be  found  in  the  cell  body.  Amitotic 
nuclear  division  figures  are  not  uncommon. 


23 


PLATE    VI 

Figures  12  to  14  show  some  of  the  above  described 
leucocytes,  as  well  as  a  comparison  in  appearance 
and  size  between  one  another,  and  the  erythrocytes. 

Figure  12. — Two  Eosinophiles  and  Two  Transi- 
tionals.     Magnification  750 

In  the  eosinophiles,  the  characteristic  configuration 
of  the  nucleus  and  the  arrangement  of  the  distinctly 
stained  granules  are  particularly  evident.  The  two 
transitionals  present  characteristics  by  means  of 
which  they  are  easily  distinguished  from  polymor- 
phonuclear neutrophiles  (see  Fig.  6).  A  few  blood 
platelets  are  seen  on  the  left. 

Figure  13. — Two  Transitionals  and  Two 
Basophiles.     Magnification  750 

The  upper  transitional  appears  as  a  large  mono- 
nuclear leucocyte.  Close  inspection  shows  an  in- 
dented and  constricted  nucleus.  The  lower  transi- 
tional has  a  lobular  nucleus  and  is  probably  a  more 
mature  cell. 

Two  basophiles  are  seen  on  the  right  with  differ- 
ently shaped  nuclei  and  coarsely  granular  protoplasm. 


24 


Plate  VI.     Figs.  12,  13 


Plate  VII.     Figs.  14,  15 


PLATE    VII 

Figure  14. — Lymphocytes.     Magnification  750 

The  lymphocytes  shown  in  the  picture  represent 
an  infrequently  observed  type,  and  may  occasion 
diagnostic  difficulty.  The  two  upper  cells  illustrate 
the  maximum  size  of  the  usually  much  smaller  lym- 
phocyte. The  nuclei  are  poor  in  chromatin  and  show 
distinct  nucleoli.  The  acidophilic  granules  are  well 
brought  out  by  the  Romanowsky  stain  in  all  three  of 
the  cells. 

Figure  15. — Degeneration  Forms  of  Leucocytes. 
Magnification  750 

Two  neutrophiles  are  seen  above,  two  lymphocytes 
to  the  left,  a  transitional  below,  a  Turk's  irritation 
form  on  the  right  and  an  eosinophile  in  the  center. 

All  these  cells  show  vacuoles  varying  in  size  and 
number.  These  changes  are  usually  noted  in  speci- 
mens from  much  debilitated  or  moribund  patients 
many  hours  before  death.  One  of  the  polymorpho- 
nuclear neutrophiles  in  the  picture  has  been  dis- 
tended, and  finally  ruptured  by  the  increase  in  size 
of  the  vacuoles. 

In  the  transitional,  the  zonal  stain  and  the  marginal 
arrangement  of  the  vacuoles  are  noteworthy,  and 
probably  due  to  lessened  resistance  at  the  periphery 
of  the  protoplasm. 

The  occurrence  of  this  vacuolar  degeneration  in  a 
large  number  of  leucocytes  would  thus  seem  to  be  a 
bad  prognostic  sign. 


25 


PLATE    VIII 

THE   VARIETIES   OF   LEUCOCYTOSIS 

Neutrophilic  JLeucocytosis 

The  diagnosis  of  this  condition  is  based  not  only 
on  an  increase  in  the  relative  percentage  of  polymor- 
phonuclear neutrophils  in  the  differential  count  but 
also  on  an  absolute  increase  as  well.  The  lowest 
figures  which  constitute  a  neutrophihc  leucocytosis 
are  approximately  8,000  neutrophiles  in  1  c.mm.,  the 
total  leucocyte  count  being  about  10,000.  The  maxi- 
mum figures  are  indefinite,  but  counts  over  60,000 
neutrophiles  in  1  c.mm.  are  rare.  This  is  the  most 
common  type  of  leucocytosis.  The  lymphocytes  and 
eosinophiles  are  usually  decreased  both  in  relative 
percentage  and  in  absolute  numbers. 


Female,  16  years  old.  Pleurisy  and  Exudative  Pericarditis. 
I,eucocytes,  .34,200  in   1   c.mm. 

Figure  16. — Neutrophilic  Leucocytosis.  Moist 
Double  Cover-glass  Specimen.  Magnifica- 
tion 750 

The  erythrocytes  are  normal  in  appearance.  The 
white  corpuscles,  relatively  increased  in  number  as 
con)j)ared  to  tlie  erythrocytes,  arc  seen  to  be  large 
polymorphonuclear  cells  with  finely  granulated  proto- 
plasm, indicating  that  they  are  polymorphonuclear 
neutrophiles.     Some  show  ameboid  motion. 


26 


Plate  VIII.     Fig.  16 


Plate  IX.     Fig.  17 


PLATE    IX 

Figure  17. — Neutrophilic  Leucocytosis.     Stained 
Film.     Magnification  330 

[The  same  case.] 

The  red  corpuscles  show  slight  variations  in  color 
due  to  the  shght  anemia.  Sixteen  polymorphonuclear 
neutrophiles  and  one  transitional  are  seen  in  the  field. 
The  hlood  platelets  are  somewhat  increased  in 
number. 


27 


PLATE    X 

EOSINOPHILIC    LEUCOCYTOSIS 

The  increase  in  the  number  of  eosinophiles  in  this 
type  of  leucocytosis  is  relatively  less  marked  than  the 
increase  of  neutrophils  in  neutrophilic  leucocytosis, 
and  corresponds  approximately  to  the  relative  pro- 
portions in  normal  blood  in  which  there  are  about  150 
to  300  eosinophiles  in  1  c.mm.  The  presence  of  6  per 
cent,  or  more  eosinophiles  in  the  differential  count 
constitutes  an  eosinophiha  when  the  absolute  count  is 
correspondingly  increased.  This  condition  is  noted 
chiefly  in  bronchial  asthma,  skin  disease,  helminthiasis 
and  particularly  in  trichinosis. 

Male,  31  years  old.  Trichinosis.  Total  leucocyte  count  18,000 
in  c.mm.  Differential  count  shows  49.6  per  cent,  eosinophiles  or 
8,930  in  1  c.mm. 

Figure  18. — Eosinophilic  Leucocytosis.     Stained 
Film.     Magnification  330 

Erythrocytes  unchanged.  Numerous  leucocytes 
are  seen  in  the  field,  the  majority  (17)  of  which  are 
eosinophiles,  which  are  easily  identified  though  the 
granular  stain  is  imperfect.  Four  neutrophiles  are 
seen  in  the  center  and  above  these  there  are  two 
lymphocytes  and  one  transitional. 


28 


PLATE    XI 

Figure  19. — Neutrophilic  Leucocytosis.     Stained 
Film.     Magnification  750 

The  polymorphonuclear  type  of  the  cells  indicates 
that  they  are  neutrophiles.  The  granulation  of  the 
protoplasm  is  denser  than  in  normal  blood,  a  change 
usuallj'^  noted  in  leucocytosis.  The  blood  platelets 
vary  in  size  and  are  increased  in  number. 

Figure  20. — Eosinophilic  Leucocytosis.     Stained 
Film.     Magnification  750 

[Till'  same  case  as   Figure   18.] 

The  decided  increase  in  the  number  of  eosinophiles 
is  evident.  The  cells  are  somewhat  smaller  than  the 
usual  eosinophile,  and  some  shovp^  granulations  on  the 
nucleus. 


29 


PLATE    XII 

Girl,  3  years  old.  Chronic  intestinal  catarrh.  Leucocytes 
14,000  in  1  c.mm.  Diflferential  count  shows  48  per  cent,  lym- 
phocytes or  6,500  in  1  c.mm. 

Figure  21. — Leucocjrtosis  in  a  Child.    Stained 
Film.    Magnification  330 

While  a  true  neutrophilic  leucocytosis  may  occur 
in  children,  the  simultaneous  increase  in  neutrophiles 


a.  I'olyniorphonuclear  Neutrophile*. 

6.  Lympliocytes. 

o.  Transitionals. 

d.  Tiirk'a  irritation  forma. 

80 


Plate  X.      Fig.  18 


Plate  XI.      Figs.  19,  20 


and  in  mononuclear  forms,  particularly  the  lympho- 
cytes, is  the  most  freciuent  type  of  leucocytosis. 

Atypical  forms  of  leucocytes  are  frequently  seen  in 
these  cases,  such  as  neutrophiles  with  round  nuclei, 
Tiirk's  irritation  forms,  and  myelocytes,  their  number 
serving  as  an  index  to  the  gravity  of  the  disease.  The 
red  corpuscles  show  no  particular  change. 


31 


PLATE    XIII 

Child,  6  years  old.  Septic  diphtheria  of  nose,  fauces  and 
larynx.  Duration  8  days.  Cutaneous  hemorrhages.  Blood  ex- 
amination 6  hours  before  death  shows:  Hemoglobin,  100  per 
cent.;  red  cells,  4,388,000;  leucocytes,  72,000. 

Figure  22. — Blood  Changes  in  Diphtheria. 
Stained  Film.     Magnification  750 

In  fatal  cases  of  diphtheria  in  addition  to  the  usual 
neutrophilic  leucocytosis,  numerous  neutrophilic  mye- 
locytes are  found,  while  these  are  not  noted  in  favor- 
able cases.  Turk's  irritation  forms  and  mononuclear 
neutrophiles  also  may  occur  in  the  favorable  cases, 
and  have  no  particular  significance,  but  the  presence 
of  myelocytes  must  always  be  regarded  as  an  unfavor- 
able prognostic  sign. 

Six  neutrophilic  leucocytes  are  seen  in  the  field;  to 
the  right  there  is  a  small  lymphocyte  with  scarcely 
visible  protoplasm,  toward  the  center  a  distorted 
transitional,  and  adjoining  this  there  are  two  neu- 
trophilic myelocytes,  their  irregular  outline  due  to 
pressure.  The  red  corpuscles  show  evidences  of  some 
anemia. 


Male,  22  years  old.  Typhoid  fever,  26th  day.  Hemoglobin,  80 
per  cent.;  red  cells,  4,510,000;  leucocytes,  6,300.  Differential 
Count:  Neutrophiles,  38.5  per  cent,  or  2,400;  lymphocytes,  53.8 
per  cent,  or  3,400;  transitionals,  5  per  cent.;  eosinophiles,  2.4 
per  cent. ;  basophiles,  none ;  irritation  forms,  0.3  per  cent. 

Figure  23. — Lymphocytosis.     Stained  Film. 
Magnification  750 

Lymphocytosis  consists  of  an  increase  in  the  rela- 
tive percentage  as  well  as  in  the  actual  number  of 

32 


Plate  XII.     Fig.  21 


normal  lymphocytes,  which  are  derived  in  large  num- 
bers from  lymph  glands  by  virtue  of  pathological 
change  or  stimulus.  The  condition  is  observed  in 
whooping  cough,  rickets,  syphihs  and  typhoid  con- 
valescence, and  follows  injections  of  tubercuhn. 

In  the  illustration,  the  red  cells  show  pale  centers 
owing  to  diminished  hemoglobin.  Three  lympho- 
cytes, and  one  neutrophile  practically  without  gran- 
ules, are  seen  in  the  field.  The  lymphocytes  all  belong- 
to  the  large  type,  and  one  shows  shght  acidophihc 
granulation  of  its  protoplasm. 


33 


PLATE    XIV 

THE  RED  CORPUSCLES  OF  THE  HUMAN  BLOOD  AND  THE 
BLOOD   PLATELETS 

Figure  24. — Erythrocytes.     Magnification 
750 

Normal  Erythrocytes  are  round  disks  with  an  aver- 
age diameter  of  7  to  7^  microns,  the  margin  often 
staining  deeper  than  the  center. 

Microcytes  are  abnormally  small  ery1;hrocji;es, 
round  or  deformed,  with  a  normal  or  pale  hemoglobin 
tint.     They  are  to  be  considered  degeneration  forms. 

Macrocytes  are  abnormally  large  erythrocytes, 
usually  quite  round,  frequently  polychromatophilic, 
and  rarely  showing  a  uniform  hemoglobin  tint. 
They  represent  preliminary  stages  of  the  normal 
erythrocyte. 

Poikilocytes  are  deformed  erythrocytes,  usually 
bottle  or  pear  shaped,  and  often  very  irregular.  The 
hemoglobin  content  is  always  more  or  less  diminished. 
They  are  considered  degeneration  forms  which  have 
lost  their  normal  contour  on  account  of  lessened 
resistance. 

Figure  25. — Nucleated  Red  Corpuscles   (Erythro- 
blasts).     Magnification  750 

Erythroblasts  represent  preliminary  stages  of  nor- 
mal red  blood  cells,  their  appearance  in  the  periph- 
eral blood  indicating  increased  activity  of  the  bone 
marrow  in  the  formation  of  erythrocytes. 

Normoblasts  are  of  the  same  size  as  erythrocytes 
and  have  a  relatively  large  round  nucleus  showing 

84 


Plate  XIII.      Fig..  22,  23 


radiating  or  segmented  structure.  The  cell  body  of 
the  mature  normoblast  has  a  pure  hemoglobin  tint, 
but  the  younger  cells  are  frequently  polychromato- 
philic. 

3Iicroblasts  are  characterized  by  their  small  size, 
and  show  degenerative  changes  of  the  cell  body 
(poikilocytosis),  and  pycnotic  nuclei  of  dense  struc- 
ture, which  stain  deeply.  Free  microblast  nuclei  are 
sometimes  seen,  and  are  easily  differentiated  from 
other  structures  by  their  small  size  and  dark  blue 
color. 

Megalohlasts  are  two  or  three  times  the  size  of 
normoblasts,  and  the  older  forms  have  a  relatively 
small  nucleus.  Polycliromatophihc  megalohlasts  are 
not  uncommon,  and  present  large,  loose  structured 
nuclei,  poor  in  chromatin.  The  megaloblast  origi- 
nates from  a  pathologically  altered  regeneration  of 
the  blood  with  a  reversion  to  the  embryonic  type. 

Nuclear  Division  Figures  of  Erythroblasts.  Ami- 
totic (direct)  division  is  more  frequently  observed  in 
megalohlasts  than  in  normoblasts.  Attention  to  the 
hemoglobin  or  polychromatophihc  stain  of  the  cell 
body  differentiates  these  cells  from  lymphocji;es  of 
similar  appearance,  in  which  the  nucleus  may  also 
undergo  amitotic  division,  but  the  cell  body  is  always 
basophihc  (blue). 

Mitotic  division  is  rarely  observed  in  the  leukemias 
and  in  pernicious  anemia.  The  nuclear  division 
figures  are  often  large  and  beautifully  marked  with 
more  or  less  distinct  diaster  formation.  The  cell  body 
is  still  slightly  basophilic  and  usually  shows  basophilic 
granulation. 

Figure  26. — Blood  Platelets.    Magnification 

750 

These  are  blood  elements  of  various  shapes,  which 
range  in  size  from  some  scarcely  visible,  to  others 
with  a  diameter  of  10  microns.  The  smallest  forms 
appear  as  pale,  sharply  circumscribed  disks,  which 

3S 


may  have  crenated  margins,  and  show  a  nuclear  sub- 
stance also  varying  in  size  and  often  with  only  few 
chromatin  granules. 

The  larger  forms  are  oval  or  rod-shaped,  with 
abundant  nuclear  substance  of  a  dark  chromatin 
tint.  These  may  show  processes  varying  in  length 
up  to  twice  the  diameter  of  the  platelet,  which  also 
contain  chromatin  (see  Fig.  40). 

Ordinarily,  the  platelets  occur  in  small  groups,  or 
singly,  but  in  the  blood  of  persons  having  mahgnant 
tumors  they  may  be  found  aggregated  in  large 
numbers. 

The  origin  and  the  significance  of  the  platelets  are 
still  obscure.  They  are  usually  foimd  increased  in 
number  during,  and  after,  all  conditions  associated 
with  leucocytosis,  or  with  disintegration  of  leucocytes. 
They  are  enormously  increased  in  myelogenous 
leukemia. 

The  practical  method  of  determining  their  number 
is  by  means  of  an  approximate  estimate  in  the  stained 
fihn*. 


86 


Plate  XIV.     Figs.  24,  25,  26 


26 


■*1 

V 

'«3 

<• 

«»> 

^       « 

a     , 

'i- 

4 

1 

\ 

••?:t^^_; 

'  ■  •  "  ■ 

PLATE    XV 

THE   ANEMIAS 

Polychro  matopMUs 

This  term  indicates  a  changed  behavior  of  the 
erythi-ocytes  toward  the  stain.  PolychromatophiUc 
erythrocytes  show  a  mixed  staining  quahty  varying 
from  an  ahnost  pm-e  eosin  to  a  dirty  blue  or  violet. 
In  the  more  marked  instances  the  corpuscles  appear 
spotted  as  if  occupied  by  a  basophilic  stroma. 

The  condition  is  found  in  all  stages  of  development 
of  the  immature  erythrocyte,  particularly  in  the 
nucleated  cells,  and  those  showing  nuclear  division 
figures.  It  is,  therefore,  regarded  as  a  sign  of  imma- 
turity of  the  red  corpuscle,  and  consequently  a  symp- 
tom of  increased  regeneration. 

Figure  27. — Karyolytic  Forms  of  Erythroblasts. 
Magnification  750 

These  are  often  present  in  large  numbers  in  cases 
of  progressive  severe  anemia,  and  particularly  in  the 
anemia  of  congenital  syphiMs  in  children. 

The  nuclei  are  extremely  varied  in  appearance  and 
show  budding  and  constrictions  with  pycnotic  seg- 
ments, A  small  nucleus,  poor  in  chromatin,  is  some- 
times seen  in  a  polychromatophiHc  cell,  apparently 
a  remnant  of  an  original  nucleus  which  has  undergone 
dissolution.  v 

Cliild,  2J/2  years  old.  Anemia  gravis  with  congenital  syphilis. 
Red  cells,    1,564,000;   leucocytes,    14,000. 

Figure  28. — PolychromatophiHc  Erythrocytes. 
Stained  Film.     Magnification  750 

The  erythrocytes  show  moderate  variations  in  size 
and  shape,  with  both  slight  and  pronounced  poly- 

37 


chromatophilia  (see  Fig.  41).  A  megaloblast  in 
process  of  division,  with  polyclu'omatophilic  cell 
body,  is  seen  above,  and  on  the  right  there  is  a  lymph- 
ocyte with  the  usual  blue  stained  protoplasm. 


88 


Plate  XV.     Figs.  27,  28 


Plate  XVI.     Figs.  29,  30 


PLATE    XVI 

BASOPHILIC    GRANULATION 

In  this  change  the  normal  erythrocyte,  or  more 
frequently  the  polychromatophilic  erythrocyte,  con- 
tains granules  whicli  take  a  basic  stain.  The  granules 
vary  in  size;  some  are  scarcely  visible  and  others  are 
as  large  as  the  neutrophihc  granules  in  leucocytes. 
Poikilocytes  and  microcytes  occasionally  contain 
unusually  large  angular  granules.  They  also  vary 
in  number,  sometimes  filhng  the  entire  cell. 

Basophihc  granulation  is  also  found  in  nucleated 
red  cells  and  in  those  presenting  nuclear  division 
figures.  Polychromatophiha  being  considered  an 
indication  of  immaturity,  the  designation  of  an 
accompanying  basophilic  granulation  as  "granular 
degeneration"  does  not  seem  justified,  but  as  yet  no 
definite  opinion  is  possible.  It  is  observed  in  all  types 
of  anemia  and  particularly  in  cases  of  lead  poisoning. 

Figure  29. — Basophilic  Granulation.     Stained 
Film.     Magnification  750 

Composite  picture  of  specimens  from  a  case  of 
chronic  lead  poisoning.  The  varieties  of  basophilic 
granulation  and  its  combination  with  polychroma- 
tophiha are  the  noteworthy  features. 

Male,  25  years  old.  Painter,  suffering  from  chronic  lead 
poisoning. 

Figure  30. — Lead  Poisoning.     Stained  Film. 
Magnification  750 

Granular  erythrocytes  are  invariably  present  in 
cases  of  lead  poisoning.    They  are  more  numerous  in 

39 


this  condition  than   in   any   other  disease,   and  the 
blood  picture  is  practically  pathognomonic. 

The  erythrocytes  show  slight  variations  in  size  and 
color.  In  some  the  color  is  limited  to  the  margins 
and  shght  polychromatophilia  is  apparent.  Nine 
red  cells  which  have  more  or  less  marked  basophilic 
granulation  are  seen  in  the  field. 


40 


PLATE  XVII 

THE    SECONDARY    ANEMIAS 

Secondary  anemia  includes  all  the  anemic  condi- 
tions developing  in  the  course  of  different  diseases 
which  are  not  based  on  the  primary  involvement  of 
the  blood-making  organs.  The  gi'oup  includes  all 
affections  leading  to  loss  of  blood,  mahiutrition  and 
cachexia  (gastric  and  intestinal  ulcers,  animal  para- 
sites, infectious  diseases,  malignant  tumors).  In 
order  to  study  the  morphology  of  the  red  corpuscles, 
in  primary  as  well  as  secondary  anemia,  it  is  essential 
to  examine  fresh  specimens,  as  the  changes  noted  in 
stained  films  are  often  artefacts. 

Secondary  Anemia.    Acute  Form 

Soon  after  a  severe  hemorrhage  there  is  a  diminu- 
tion in  the  number  of  red  corpuscles  and  in  the 
amount  of  hemoglobin,  due  to  a  transfer  of  fluids 
from  the  tissues  into  the  blood.  Regenerative  phe- 
nomena are  soon  noted  by  the  presence  of  polychro- 
matophilia,  macrocytes  and  normoblasts,  which  im- 
mature forms  are  usually  deficient  in  hemoglobin. 
The  number  of  red  cells  increases  rapidly,  while  the 
increase  in  hemoglobin  content  is  slower. 

Female,  45  years  old.  Ulcer  of  the  stomach.  Hemoglobin,  S.'j 
per  cent.;  red  corpuscles,  1,960,000;  leucocytes,  6,300  in  1  cram. 

Figure  31. — Acute  Anemia.     Stained  Film. 
Magnification  750 

The  erythrocytes  are  further  apart  in  the  stained 
specimen,  owing  to  the  dilution  of  the  blood.     The 

41 


lack  of  uniformity  in  size  is  due  to  the  presence  of 
numerous  polychromatophilic  macrocytes,  and  not 
to  changes  in  the  normal  cells.  A  polychromato- 
philic normoblast  is  seen  above  and  a  lymphocyte  be- 
low.    Several  blood  platelets  are  also  present. 

Secondary  Anemia.     Chronic  Form 

In  addition  to  the  changes  noted  above,  these 
cases  also  show  variations  in  the  shape  of  the  red 
cells  and  a  more  or  less  pronounced  diminution  in  the 
amount  of  hemoglobin.  The  red  cells  may  simply 
show  decided  loss  of  hemoglobin,  without  polychro- 
matophiha.  An  absence  of  immature  erythrocytes 
in  cases  of  secondary  anemia  justifies  a  suspicion  of 
paralysis  of  function  of  the  bone  marrow,  as  far  as 
formation  of  erythrocytes  is  concerned.  The  more 
numerous  the  immature  red  cells,  the  greater  the 
functional  activity  of  the  blood-forming  organs. 
When  the  bone  marrow  is  suddenly  called  upon  to 
supply  a  marked  deficit,  there  may  be  a  transitory 
flooding  of  the  circulation  with  many  nucleated  cells. 


Male,  54  years  old.  Carcinoma  of  stomach.  Hemoglobin,  35 
per  cent.;  red  cells,  1,336,000;  leucocytes,  13,100  in  1  c.mm. 

Figure  32. — Chronic  Anemia.     Stained  Film. 
Magnification  750 

The  red  cells  show  the  characteristic  evidences  of 
secondary  anemia,  i.  e.,  diminished  and  uneven 
hemoglobin  distribution,  polychromatophilia,  changes 
in  size  and  shape  of  corpuscles. 


42 


Plate  XVII.     Figs.  31,  32 


Plate  XVIII.     Figs.  33,  34 


PLATE    XVIII 

Figure  33. — Chronic  Anemia.     Stained  Film. 
Magnification  330 

The  same  changes  are  noted  as  in  Fig.  32,  and  the 
pathological  condition  is  particularly  apparent  when 
compared  with  Fig.  3,  which  represents  normal  blood. 

Two  neutrophils  are  seen  in  the  field,  with  a 
normoblast  above  and  numerous  blood  platelets. 

Anemia  in  Children  having  Congenital  Syphilis 

In  well  marked  cases  the  changes  in  the  red  cells 
are  sufficiently  pronounced  to  make  this  one  of  the 
cardinal  symptoms.  In  addition  to  a  leucocytosis, 
numerous  bone-marrow  cells  are  found,  which  justify 
the  l)ehef  that  the  bones  are  also  involved  in  the 
pathological  lesion  and  that  the  presence  of  these 
cells  is  the  result  of  direct  irritation  of  the  bone 
marrow  by  the  local  syphilitic  process.  Neutro- 
philic and  eosinophilic  myelocytes  and  immature 
lymphocytes  are  present,  together  with  a  large  num- 
ber of  nucleated  red  cells,  microblasts,  normoblasts 
and  frequently  megaloblasts  and  nuclear  division 
figures.  The  large  number  of  karyolytic  forms  is 
noteworthy  (see  Fig.  27).  The  red  cells  appear  de- 
ficient in  pigment,  but  poikiloc_\i;osis,  polychromato- 
philia,  and  basophilic  granulation  are  not  common. 
The  number  of  erythrocytes  is  always  considerably 
diminished,  with  a  corresponding  reduction  in  the 
amount  of  hemoglobin. 


43 


Child,  lyz  years  old.  Hereditary  syptilis.  Red  cells, 
2,500,000;  leucocytes,   18,000  in   1   c.mm. 

Figure  34.— Infantile  Hereditary  Syphilis. 
Stained  Film.     Magnification  750 

The  specimen  contained  numerous  nucleated  red 
cells  their  number  exceeding  the  total  leucocyte 
count.  The  stained  film  of  blood,  obtained  after 
death,  shows  some  disintegrating  cells. 


Normoblasts  and  Megaloblasts.  Some  of  the  latter  unusually  large, 
with  more  or  less  basophilic  protoplasm,  and  one  or  more  nuclei 
poor  in  chromatin. 

Karyolytic  Forms  of  Normoblasts  and  Megaloblasts. 

Lympliocytes.     One  with  diviiicd  Nucleus. 

Granular  and  Non-granular  Bone  marrow  Cells. 


PLATE    XIX 

SECONDARY  ANEMIAS 

Figure  35. — Chronic  Secondary  Anemia.  Fresh 
Double  Cover-glass  Specimen.  Magnifica- 
tion 750 

[Same  case  as  Figure  32.] 

The  pale  tint  of  the  red  cells  indicates  their  loss 
of  hemoglobin,  especially  when  compared  with  nor- 
mal blood. 

The  varied  outline  of  red  corpuscles  is  most  appar- 
ent in  the  fresh  specimen,  but  an  opinion  as  to  their 
size  requires  experience.  Pear-shaped  and  bottle- 
shaped  cells,  and  multilobular  poikilocytes  are  pres- 
ent, A  microcyte  is  seen  in  the  center  of  the  field. 
The  two  humped  and  oblong  red  cells  are  changes, 
due  presumably  to  evaporation,  the  details  of  which 
are  seen  in  the  following  picture. 

Figure  36. — Crenated  Erythrocytes.  Fresh  Double 
Cover-glass  Specimen.     Magnification  750 

The  illustration  shows  the  crenated  forms  of  red 
cells,  formerly  believed  to  be  the  same  thing  as 
poikilocytes.     The  characteristic  changes  are  evident. 

The  crenated  forms  may  be  observed  in  any 
specimen  of  fresh  blood  which  has  evaporated  or 
suffered  mechanical  injury.  In  fact  the  occurrence 
of  a  few  of  these  near  the  margin  can  scarcely  be 
prevented  in  the  fresh  specimens,  though  carefully 
prepared. 

Crenation  within  a  few  seconds  of  all  the  red 
corpuscles  in  a  properly  made  specimen  is  pathologi- 

45 


cal,  and  must  be  considered  an  evidence  of  lessened 
resistance  on  the  part  of  the  erythrocytes.  Error  is 
prevented  by  observing  this  in  several  successively 
prepared  specimens.  Normal  blood  does  not  show 
this  change  to  any  extent  until  after  the  lapse  of  from 
thirty  minutes  to  several  hours. 


46 


Plate  XIX.     Figs.  35,  36 


Plate  XX.     Figs.  37,  38 


PLATE    XX 


THE    PRIMARY    ANEMIAS 


The  characteristic  feature  in  the  diagnosis  of 
primary  anemia,  is  the  presence  of  anemic  conditions, 
varying  in  kind  and  degree  with  an  absence  of  all 
other  causative  diseases.  In  chlorosis  and  certain 
anemias  of  childliood,  nothing  but  an  affection  of  the 
blood  itself  has  as  yet  been  demonstrated,  whereas 
in  pernicious  anemia  the  blood-forming  organs  are 
the  seat  of  the  lesion. 

The  anemias  of  childhood  present  no  specific  or 
particularly  characteristic  changes  in  the  blood,  but 
in  chlorosis,  as  well  as  in  pernicious  anemia,  definite 
evidences  are  found,  which  are  characteristic  of  the 
one  or  the  other  condition. 

Female,  63  years  old.  Pernicious  Anemia.  Hemoglobin,  35 
per  cent.;  red  cells,  1,032,000;  leucocytes,  16,000  in  1  c.mm. 
Marked  polychromatophilia  and  pronounced  variations  in  the 
size  of  the  red  cells.     Normoblasts  and  megaloblasts  are  present. 

Figure  37. — Pernicious  Anemia.     Fresh  Double 
Cover-glass  Specimen.     Magnification  750 

Most  of  the  red  cells  are  deficient  in  hemoglobin, 
but  some  have  a  normal  color.  The  uneven  dis- 
tribution of  hemoglobin  is  always  apparent.  The 
pronounced  difference  in  the  size  of  the  corpuscles  is 
noteworthy ;  about  half  of  them  are  megalocytes,  and 
there  are  also  many  microcytes,  some  so  small  that 
they  are  difficult  to  distinguish  from  blood  platelets 
in  the  fresh  specimen. 

Poikilocytosis  was  not  a  pronounced  feature  in  this 

47 


case  of  pernicious  anemia  in  which  the  diagnosis  was 
verified  by  autopsy.  This  change  is  evidently  not 
present  to  the  same  degree  in  every  case,  and  probably 
depends  to  some  extent  on  the  duration  of  the  disease. 

Female,  28  years  old.  Chlorosis.  Hemoglobin,  50  per  cent.; 
red  cells,  4,320,000;  leucocytes,  9,600  in  1  c.mm. 

Figure  38. — Chlorosis.     Fresh  Double  Cover-glass 
Specimen.     Magnification  750 

In  chlorosis,  even  the  fresh  blood  differs  in  several 
essential  features  from  that  of  secondary  anemia  or  of 
pernicious  anemia.  Primarily,  the  erythrocytes  show 
a  uniform  decided  diminution  in  blood-coloring  mat- 
ter, which  is  very  apparent  in  severe  cases.  Poildlo- 
cji;osis  is  not  as  pronounced  in  severe  chlorosis  as 
it  is  in  severe  secondary  anemia,  and  the  marked 
difference  in  the  size  of  the  corpuscles  seen  in  perni- 
cious anemia,  is  absent.  In  cases  of  severe  hydremia 
a  uniform  increase  in  the  size  of  a  large  number  of 
erythrocytes  is  frequently  observed.  ^^Hien  the  chlor- 
osis is  not  jjronounced,  no  particularly  characteristic 
changes  can  be  made  out  in  a  fresh  specimen. 

Figure  38  shows  a  specimen  of  blood  from  a  case 
of  chlorosis.  The  red  cells  are  particularly  uniform  in 
size  and  very  pale  in  color.  Few  pear-shaped  poiki- 
locj'tes  are  present.  The  erythrocji:es,  viewed  later- 
ally, show  a  hght  zone  which  is  probably  a  reflection. 


48 


Plate  XXI.     Figs.  39,  40 


PLATE    XXI 

Girl,  26  years  old.     Severe  Chlorosis.     Hemoglobin,  35   per 
cent.;  red  cells,  4,000,000;  lymphocytes,  4,400  in  1  c.mm. 

Figure  39. — Chlorosis.     Stained  Film. 
Magnification  750 

In  chlorosis  the  diminution  in  the  amount  of 
hemoglobin  is  much  greater  than  in  the  number  of 
red  corpuscles,  and  this  characteristic  loss  of  coloring 
matter  is  apparent  in  all  the  corpuscles  by  the  narrow 
stained  rim  as  shown  in  the  illustration.  There  is 
only  a  sHght  difference  in  the  size  of  the  cells,  but 
poi'kilocytosis  is  evident.  The  platelets  are  increased 
in  number.     A  lymphocyte  is  seen  on  the  right. 

Female,  26  years  old.  Convalescing  Chlorosis.  Hemoglobin, 
90  per  cent. ;  red  cells,  4,600,000 ;  leucocytes,  7,200  in  1  c.mm. 

Figure  40. — Chlorosis.     Stained  Film. 
Magnification  750 

The  specimen  shows  the  decided  and  uniform  in- 
crease in  the  amount  of  hemoglobin  in  the  corpuscles 
during  convalescence,  but  the  pale  centers  indicate 
that  this  is  not  yet  quite  normal.  Few  poikilocytes 
are  present. 

The  flagella-like  processes  of  the  platelets  are  seen 
in  this  specimen. 


49 


PLATE    XXII 

PERNICIOUS    ANEMIA 

In  cases  of  pernicious  anemia  the  blood  as  a  rule 
presents  a  characteristic  series  of  changes  not  noted 
in  any  other  disease.  The  diminution  in  the  number 
of  red  corpuscles  is  out  of  proportion  to  the  loss  of 
hemoglobin.  In  making  the  red  cell  count,  care 
should  be  exercised  not  to  overlook  the  numerous 
microcytes  usually  present.  The  disproportionate 
loss  of  red  cells  and  hemoglobin  is  explained  by  the 
fact  that,  wliile  very  pale  corpuscles  are  seen,  there 
are  also  many  which  contain  a  normal  amount  of 
blood  pigment.  Decided  polychromatophiha  is  in- 
variably noted,  and  basophilic  granulation  is  common. 
Pronounced  poikilocytosis  seems  to  develop  only  in 
the  protracted  cases.  The  presence  of  megalocytes 
and  megaloblasts  constitutes  a  particularly  charac- 
teristic feature,  and  their  occurrence  is  explained  by  a 
megaloblastic  transformation  of  the  bone  marrow  as 
far  as  the  formation  of  red  cells  is  concerned.  Mi- 
toses of  erythroblasts  may  also  be  found.  These 
evidences  of  disintegration  and  abnormal  regenera- 
tion of  the  blood  are  not  found  in  chlorosis  or  second- 
ary anemia. 

The  leucocyte  count  in  pernicious  anemia  varies 
considerably.  Leucopenia  is  an  unfavorable  prog- 
nostic sign.  While  neutrophilic  leucocytosis  is  noted 
in  the  course  of  improvement,  it  may  also  be  indicative 
of  inflammatory  complications.  The  presence  of 
myelocytes  and  Tiirk's  irritation  forms  is  not  uncom- 
mon. 


Plate  XXII.     Fig.  41 


Figure  41. — Pernicious  Anemia.     Stained  Film. 
Magnification  750 

[Same  case  as  Figure  37.      Duration  of  disease  four  weeks.] 

The  decided  polychromatophilia  and  the  shght 
poikilocytosis  are  apparent  and  probably  explained 
by  the  severity  and  short  duration  of  the  case  Lack 
of  uniformity  in  the  distribution  of  hemoglobin  is 
also  evident,  some  cells  being  very  pale,  while  others 
seem  to  contain  an  excessive  amount  of  blood  pigment. 

Two  megaloblasts  with  pycnotic  nuclei  are  seen 
above,  to  the  right,  and  in  the  center  there  is  a 
megaloblast  with  a  large  nucleus  poor  in  chromatin 
and  a  basophiMc  cell  body.  A  Turk's  irritation  form 
is  seen  immediately  beneath  the  latter,  and  these  two 
cells  show  a  striking  resemblance.  A  megaloblast  in 
process  of  mitotic  division  is  also  seen,  and  to  the 
right  a  polymorphonuclear  neutrophile. 


51 


PLATE    XXIII 


THE   LEUKEMIAS 


The  diagnosis  of  leukemia  is  based  on  the  demon- 
stration of  a  permanent  increase  in  the  nmnber  of 
white  corpuscles  in  the  blood,  a  large  percentage  of 
which  are  bone  marrow  cells  or  abnormal  leucocytes. 
This  statement  apphes  to  myelogenous  leukemia  as 
well  as  to  lymphatic  leukemia,  and  for  the  present 
this  classification  seems  desirable,  as  it  is  based  on 
the  condition  of  the  blood.  Further  subdivisions  do 
not  seem  indicated  as  yet,  particularly  as  almost 
every  case  of  leukemia  presents  individual  charac- 
teristics. These  may  undergo  pronounced  change 
in  the  course  of  the  disease,  by  variations  in  the 
relative  proportion  of  the  different  varieties  of  cells, 
as  well  as  by  the  disappearance  of  some  and  sudden 
appearance  of  other  types. 

All  cases  show  a  more  or  less  marked  anemia, 
which  may  present  all  the  characteristics  of  a  perni- 
cious anemia,  but  some  are  seen,  with  several  hundred 
thousand  leucocytes  in  a  cubic  milhmeter,  without 
apparent  change  in  the  red  cells.  The  severity  of 
the  disease  is  appreciably  dependent  on  the  condition 
of  the  red  cells. 

A  detailed  description  of  the  changes  in  the  blood 
in  the  different  forms  of  leukemia  will  be  found  in 
connection  with  the  following  illustrations. 


62 


Plate  XXIII.     Fig.  42 


Female,  23  years  old.  Myelogenous  Leukemia.  Hemoglobin, 
65  per  cent.;  red  cells,  3,200,000;  leucocytes,  337,000  in  1  c.mm. 

Figure  42. — Myelogenous  Leukemia.  Fresh 
Double  Cover-glass  Specimen.  Magnifi- 
cation 750 

The  decided  increase  in  the  number  of  leucocytes 
is  evident.  In  this  connection  it  is  well  to  recall  that 
some  cases  of  leukemia  may  show  comparatively  low 
leucocyte  counts,  for  example,  10,000  in  1  c.mm., 
whereas  a  leucocytosis  of  i50,000  or  more  may  exist 
for  a  considerable  period.  Consequently  the  count 
alone  is  not  sufficient  for  diagnosis.  As  considerable 
practice  is  necessary  to  differentiate  the  various  types 
of  leucocytes  in  a  fresh  unstained  specimen,  and  some 
cannot  be  recognized  in  this  waj"  at  all,  the  dried  and 
stained  films  are  preferable  for  the  purpose. 

The  red  cells  show  no  essential  change.  The  fol- 
lowing four  types  of  leucocytes  can  be  recognized  in 
the  illustration: 

a.  Polymorphonuclear  finely  granular  forms,  noted 
in  Fig.  16,  are  neutrophiles. 

b.  Cells  of  the  same  size  with  round  or  lobulated 
nuclei  and  coarse  refractive  granulation  are  eosino- 
philic myelocytes  or  eosinopliiles. 

c.  Larger  and  lighter  cells  with  round  nuclei  and 
finely  granular  protoplasm  are  bone  marrow  cells, 
which  can  be  more  accurately  classified  in  the  stained 
specimen. 

d.  Small  leucocytes  of  different  forms  which  also 
cannot  be  classified  in  the  unstained  specimens. 

The  greater  the  variety  of  leucocytes  present,  the 
more  difficult  the  classification,  in  unstained  speci- 
mens. 


53 


PLATE    XXIV 

Male,  62  years  old.  Myelogenous  Leukemia.  Blood  very  con- 
centrated. Hemoglobin,  105  per  cent.;  red  cells,  6,184,000; 
leucocytes,  59,300  in  1  c.mm. 

Figure  43. — Myelogenous  Leukemia.     Fresh 
Double  Cover-glass  Specimen.     Magnifi- 
cation 750 

The  addition  of  a  few  drops  of  an  aqueous  solution 
of  gentian  violet  to  the  diluting  fluid  differentiates 
the  leucocytes  somewhat  (compare  Fig.  42),  but  is 
not  sufficient  for  the  proper  classification  and  recog- 
nition of  the  pathological  forms.  The  red  cells  show 
but  little  change  in  shape  and  size.  A  group  of  blood 
platelets  is  seen  in  the  center,  on  the  right  a  poly- 
morphonuclear neutrophile,  on  the  left  two  granular 
bone-marrow  cells  and  above  a  lymphocyte. 

Figure  44. — Myelogenous  Leukemia.     Stained 
Film.     Magnification  750 

[The  same  case.] 

The  various  characteristics  of  the  different  varieties 
of  leucocytes  are  apparent  in  the  stained  specimen. 
In  the  fresh  specimen,  for  example,  it  is  impossible 
to  distinguish  the  neutrophihc  myeloc>i;e  from  the 
basophilic  mononuclear,  as  the  vesicular  structure 
of  the  latter  looks  just  like  the  fine  granulation  of  the 
former. 

The  red  cells  show  evidence  of  considerable  anemia. 
While  undue  concentration  of  the  blood  has  given 
normal  hemoglobin  and  red  cell  figures  as  above,  the 
anemic  changes  of  the  red  cells  are  made  apparent 

64 


Plate  XXIV.     Figs.  43,  44 


in  the  stained  specimen  by  differences  in  size,  irregu- 
larity in  shape,  polychromatophiha  and  the  presence 
of  normoblasts.  A  megaloblast  is  seen  above  and 
a  normoblast  below,  both  showing  polychromato- 
phiha. Two  polymorphonuclear  neutrophiles  and 
blood  platelets  are  also  present.  The  other  cells  will 
be  described  later. 


55 


PLATE    XXV 

CHKONIC    LYMPHATIC   LEUKEMIA 

Chronic  lymphatic  leukemia  is  characterized  by 
the  presence  in  the  blood  of  varying  numbers  of 
abnormal  Ij'mphocytes,  usually  of  the  small,  but 
occasionally  of  the  large  type.  The  absolute  counts 
are  generally  high,  ranging  from  50,000  to  1,000,000 
in  1  c.nmi.  The  relative  percentage  of  these  lym- 
phocj^es  is  also  high,  ranging  from  95  to  99  per  cent, 
of  the  leucocytes,  there  being  an  absolute  decrease  in 
the  other  varieties. 

The  appearance  of  the  blood  is  not  complex,  and 
is  absolutely  characteristic  of  the  condition. 

The  red  corpuscles  are  usually  in  fair  condition, 
and  only  show  extensive  change  in  the  advanced  and 
terminal  stages  of  the  disease,  when  there  is  a  de- 
crease in  their  number  and  a  corresponding  loss  in 
the  amount  of  hemoglobin. 

The  blood  platelets  are  slightly,  if  at  all,  increased 
in  numbers. 


Male,  't-i  years  old,  sick  for  one  year.  Multiple  swellings  of 
lymphatic  glands.  Spleen  enlarged,  and  extending  to  the  median 
line.  Progressive  anemia  for  the  past  three  months.  Duration 
of  disease  eighteen  months. 

A  complete  examination  of  the  blood  could  not  be 
made,  but  the  stained  film  justifies  a  diagnosis  of 
chronic  lymphatic  leukemia. 


56 


Plate  XXV.     Fig.  45 


••  •  • 


o 


Figure  45. — Chronic  Lymphatic  Leukemia. 
Stained  Film.     Magnification  330 

The  increase  in  the  number  of  lymphocytes  is  such 
that  there  are  more  white  than  red  cells.  The 
lymphocytes  all  appear  of  approximately  the  same 
size  and  show  a  very  narrow  margin  of  protoplasm, 
barely  visible  in  some.  There  are  a  few  somewhat 
larger  lymphocytes  with  a  lighter  colored  nucleus. 
An  abnormal  segmentation  of  the  nuclei  is  noted 
which  is  foreign  to  lymphocytes  in  normal  blood. 
(For  details  see  Fig.  47.) 

The  red  cells  show  no  change  except  diminished 
hemoglobin  content. 


S7 


PLATE    XXVI 

Figure  46. — Chronic  Lymphatic  Leukemia.  Fresh 
Double  Cover-glass  Specimen.  Magnification 
750 

[For  detailed  condition  of  the  blood  see  description  of  Fig.  IS.] 

The  nuclei  of  the  lymphocytes  are  stained  light 
blue  by  the  addition  of  a  drop  of  aqueous  solution  of 
gentian  violet  to  the  diluting  fluid.  Nothing  ab- 
normal is  apparent  in  the  lymphocytes  of  this  wet 
specimen,  except  that  they  appear  a  little  larger  than 
those  in  normal  blood.  A  polymorphonuclear  neu- 
trophile  is  seen  on  the  right.  The  red  cells  show  a 
normal  amount  of  coloring  matter. 

Figure  47. — Chronic  Lymphatic  Leukemia. 
Stained  Film.    Magnification  750 

[The  same  specimen  as  in  Fig.  45.] 

A  thin  smear  is  essential  in  order  to  recognize  the 
abnormal  features  of  the  lymphocytes  in  chronic 
lymphatic  leukemia,  as  they  differ  considerably  from 
the  small  lymphocytes  of  normal  blood.  They  are 
larger  and  have  apparently  segmented  nuclei,  poor 
in  chromatin,  which  jjractically  fill  the  cells  and 
lend  the  impression  of  immaturity.  There  is  a  nar- 
row margin  of  protoplasm,  sometimes  barely  visible. 
Acidophilic  granules  cannot  be  demonstrated. 

These  cells  must  be  considered  immature  lympho- 
cytes representing  a  definite  stage  in  the  development 
of  the  lymphocytes  of  normal  blood. 

The  red  corpuscles  are  somewhat  deficient  in 
hemoglobin. 

58 


Plate  XXVI.     Figs.  46,  47 


Plate  XXVII.     Fig.  48 


PLATE    XXVII 

Male,  38  years  old.  For  past  eighteen  months  progressive 
glandular  swellings  in  the  neck  and  both  axills.  At  present  all 
sui)erficial  glands  are  palpable  and  about  the  size  of  a  plum. 
Spleen  10  X  7  cm.  The  blood  has  normal  appearance  and  con- 
centration. Hemoglobin,  115  per  cent.;  red  cells,  4,928,000; 
leucocytes,  79,000  in  1  c.mm.  Differential  count:  Polymor- 
phonuclear neutrophiles,  5.2  per  cent.  (4,090) ;  lymphocytes, 
94.2  per  cent.  (74,390);  transitionals,  0.4  per  cent.  (370); 
eosinophiles,  0.2  per  cent.    (150). 

Diagnosis:  Chronic  Lymphatic  Leukemia. 

Figure  48. — Chronic  Lymphatic  Leukemia. 
Stained  Film.     Magnification  330 

The  increase  in  the  number  of  lymphocji;es  is  not 
nearly  as  great  in  this  case  as  in  Fig.  45.  Most  of 
the  cells  show  the  characteristics  described  above.  A 
few  of  the  lymphocytes  have  a  larger  amount  of 
protoplasm,  and  others  show  an  irregular  or  notched 
nucleus.  On  the  right  is  seen  a  nuclear  figure,  poor 
in  chromatin,  which  looks  like  a  flattened  nuclear 
remnant,  but  really  has  a  different  significance,  as 
seen  in  Fig.  49. 

The  red  cells  are  practically  normal.  The  plate- 
lets are  increased  in  numbers. 


59 


PLATE    XXVIII 

Male,  56  years  old.  During  the  past  four  years  he  has  liad 
glandular  swellings  on  both  sides  of  the  neck,  with  periods  of 
remission.  Renewed  swelling  has  been  present  for  the  past  year 
with  the  addition  of  glandular  enlargement  in  both  axilla,  in  the 
inguinal  folds,  near  the  eyes  and  at  the  angle  of  the  jaw.  Spleen 
is  considerably  enlarged  (25  X   ^^  cm.).     Moderate  cachexia. 

Hemoglobin,  105  per  cent.;  red  cells,  5,176,000;  leucocytes, 
53,600  in  1  c.mm.  Differential  count:  Polymorphonuclear  neu- 
trophiles,  6.2  per  cent,  or  3,400;  lymphocytes,  92.7  per  cent,  or 
50,000,  of  which  16.5  per  cent,  or  8,900  are  large  fragile  forms. 
Transitionals  and  eosinophiles,  0.55  per  cent,  each,  or  300  each 
in  1  c.mm. 

Diagnosis:  Chronic  Lymphatic  Leukemia. 

Figure  49. — Chronic  Lymphatic  Leukemia. 
Stained  Film.     Magnification  750 

In  addition  to  the  abnormal  lymphocytes  described 
above,  almost  every  case  of  chronic  lymphatic  leuke- 
mia shows  fragmentary  nuclear  structures  poor  in 
chromatin.  The  nucleus  often  has  the  appearance 
of  being  partially  dissolved,  and  looks  hke  a  granular 
mass  devoid  of  protojilasm.  Well  preserved  cells  of 
this  type  are  rarely  seen,  justifying  the  inference  that 
they  are  very  fragile  and  non-resistant,  or  that  they 
cannot  exist  in  the  peripheral  circulation.  Some  of 
these  resemble  large  lymphocytes,  while  others  are 
like  large  homogeneous,  slightly  basophilic  bone 
marrow  cells.  Their  nuclei,  poor  in  chromatin,  are 
indented  or  lobulated,  rarely  showing  nucleoli. 

These  large  cells  must  be  considered  as  tlie  large 
homogeneous  bone  marrow  cells  whicli  enter  the  cir- 
culation at  this  stage  of  their  development. 

In  another  case  where  the  ordinary  type  of  small 

60 


Plate  XXVIII.      Fig.  49 


lymphocytes  was  usually  present,  the  author  noted 
two  short  periods  during  which  the  blood  contained 
large  numbers  of  these  "fragile  cells,"  which  would 
seem  to  indicate  a  specific  irritation  of  the  bone 
marrow. 

When  this  large  type  of  cell  occurs  in  chronic 
lymphatic  leukemia,  it  seems  reasonable  to  conclude 
that  there  is  also  a  lesion  of  the  bone  marrow. 


61 


PLATE    XXIX 

Myelogenous  Leukemia 

Contrary  to  the  rather  uniform  changes  in  the 
blood  noted  in  chronic  lymphatic  leukemia,  the  cases 
of  myelogenous  leukemia  present  a  most  varied  and 
sometimes  confusing  picture.  All  types  of  leucocytes 
found  in  normal  blood  are  present,  in  addition  to 
myelocytes  in  different  stages  of  development.  The 
leucocyte  count  is  always  high,  ranging  usually  be- 
tween 200,000  and  2,000,000,  and  figures  below 
50,000  in  1  c.mm.  are  rare. 

The  leucocyte  count  may  recede  several  thousand 
as  the  result  of  intercurrent  febrile  disorders  (sepsis, 
tuberculosis,  etc.),  or  therapeutic  measures  (arsenic, 
X-ray,  etc.),  but  myelocytes  are  invariably  present 
in  the  peripheral  circulation,  even  under  these  cir- 
cumstances, and  the  diagnosis  of  myelogenous  leuke- 
mia is  evident. 

While  there  is  an  increase  in  the  actual  number  of 
each  variety,  the  polymorphonuclear  neutrophile  is 
the  normal  cell  to  which  this  applies  chiefly  The 
myelocytes  also  show  high  figures,  and  several  hun- 
dred thousand  may  be  present  in  1  c.mm.  One  or 
other  type  of  these  bone  marrow  cells  usually  pre- 
dominates during  the  entire  course  of  the  disease, 
and  the  different  types  are  rarely  present  in  equal 
numbers. 

The  diagnosis  of  myelogenous  leukemia  can  be 
made  on  examination  of  the  blood,  even  if  the  leuco- 
cyte count  is  not  excessive.  In  addition  to  the  leu- 
cocyte increase,  these  cases  invariably  show  changes 
in  the  red  cells  which  are,  however,  not  as  pronounced 

62 


as  in  acute  leukemia.     The  blood  platelets  are  al- 
ways decidedly  increased  in  number. 

The  seven  plates  on  the  following  pages  illustrate 
four  types  of  myelogenous  leukemia,  each  charac- 
teristic on  account  of  the  predominance  of  special 
cellular  types. 


68 


Female,  25  years  old.  Has  been  ill  for  the  past  three  years, 
and  under  treatment  for  leukemic  enlargement  of  the  spleen  for 
two  years.  Occasional  periods  of  improvement,  due  to  adminis- 
tration of  arsenic.  On  admission  to  hospital  rather  pale  and 
emaciated.  Has  a  greatly  enlarged  spleen  extending  to  the 
symphysis,  and  numerous  cutaneous  thrombi. 

The  blood  is  thin  and  coagulation  is  retarded.  Hemoglobin,  70 
per  cent. ;  red  cells,  3,300,000 ;  leucocytes,  390,000  in  1  c.mm. 
Differential  count:  Neutrophiles,  43.07  per  cent.,  or  168,000; 
lymphocytes,  1.88  per  cent.,  or  7,000;  transitionals,  2.31  per  cent., 
or  9,000;  eosinophiles,  3.46  per  cent.,  or  13,500;  basophiles,  12.17 
per  cent,  or  47,500;  myelocytes,  37.11  per  cent.,  or  145,000  in 
1  c.mm. 

Diagnosis:  Myelogenous  Leukemia. 

Figure  50. — Myelogenous  Leukemia.     Stained 
Film.    Magnification  330 

The  difference  between  the  appearance  of  the  blood 
in  this  disease  and  that  in  chronic  Ipnphatic  leukemia 
(Fig.  45)  is  immediately  apparent.  The  number  of 
leucocytes  seems  much  greater  than  in  the  most 
severe  leucocj-iosis.  The  neutrophiles,  identified  by 
their  polymorphonuclear  character,  are  in  excess  of 
other  forms.  Normal  lymphocytes  are  not  present 
in  this  field.  Eosinophiles  and  basophiles  are  in- 
creased in  number.  The  presence  of  leucocytes  which 
do  not  occur  in  normal  blood  is  the  striking  feature 
in  the  picture,  although  a  low  power  is  used.  These 
are  eosinophilic  myelocytes  and  large  cells  with  round 
nuclei  and  considerable  protoplasm  which  demand  a 
higlier  power  for  close  study.  The  red  corpuscles  are 
pale;  a  normoblast  is  seen  above  and  anotlier  below 
toward  the  left.  Blood  platelets  are  increased  in 
number. 


64 


Plate  XXIX.     Fig.  50 


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Plate  XXX.     Fig.  51 


PLATE    XXX 

Figure  51. — Myelogenous  Leukemia. 
Film.     Magnification  750 


Stained 


[The  same  specimen.] 

The  diversity  of  the  cellular  forms  in  the  specimen 
was  such  that  all  could  not  be  included  in  this  com- 
posite picture. 


a.  Polymorphonuclear  neutrophile.  h.  Eosinoplnle.  c.  Basoph  le,  in 
eluding  abnormal  forms  usually  abundant  in  myelogenoua  leukemia,  o. 
Eosinophilic  myelocytes.  These  cells  vary  considerably  in  size  nave 
large,  pale  round  or  indented  nuclei,  which  are  frequently  indistinct.  lUe 
protoplasm  is  basophilic  and  usually  distended  with  eosinophilic  gran- 
ules. Some  basophilic  granules  may  be  found  mixed  with  the  eosino- 
philic in  the  unusually  small  cells  of  this  type.  e.  Homogeneous  mono- 
nuclears with  basophilic  protoplasm  and  nuclei  in  different  stages  of 
development  showing  nucleoli.  /.  Homogeneous  mononuclears  with  baso- 
philic protoplasm  showing  slight  neutrophilic  granulation,  g.  A  more 
mature  lymphocyte,  h.  Disintegrating  eosinophile.  i.  Nuclear  remHant 
with  nucleolus  and  nuclein  strands,     fc.  "Fragile  Form." 

65 


A  normoblast  is  present  ( 1 ) .  Polychromatophilia 
and  basophilic  granulation  in  red  cells  can  be  seen. 
There  are  also  many  blood  platelets. 

No  neutrophilic  myelocytes  present. 


66 


PLATE    XXXI 

MYELOGENOUS     LEUKEMIA 

The  same  case  after  the  administration  of  arsenic 
and  use  of  X-ray.  Complicated  by  extensive  tuber- 
culous lesion  of  both  lungs.     Two  days  before  death. 

Hemoglobin,  55  per  cent. ;  red  cells,  2,34 4,000 ;  leucocytes, 
78,900  in  1  c.mm.  Differential  count:  Polymorphonuclear  neu- 
trophiles,  56,630,  or  70.42  per  cent. ;  lymphocytes,  9,270,  or 
11.75  per  cent.;  transitionals,  2,780,  or  3.52  per  cent.;  basophiles, 
930,  or  1.20  per  cent.;  myelocytes,  10,390,  or  13.14  per  cent. 
Of  the  latter,  neutrophilic  myelocytes,  6,490,  or  8.20  per  cent. ; 
eosinophilic  myelocytes,  190,  or  0.24  per  cent.;  immature  stages 
of  neutrophilic  myelocytes,  3,710,  or  4.70  per  cent. 


Figure  52. — Myelogenous  Leukemia.     Stained 
Film.    Magnification  750 

The  character  of  the  specimen  has  undergone  a 
complete  change.  While  a  decided  polymorpho- 
nuclear neutrophile  leucocytosis  is  present,  a  distinct 
leukemic  composition  is  still  apparent.  The  diminu- 
tion in  the  number  of  eosinophiles,  myelocytes  and 
basophilic  cells  as  compared  with  the  former  specimen 
is  noteworthy;  these  having  been  replaced  by  neu- 
trophilic myelocytes  and  immature  forms  of  this 
type.  This  change  is  doubtless  the  result  of  the 
tuberculous  infection,  as  it  was  not  noted  during  the 

67 


improvement  caused  by  the  administration  of  arsenic 
and  the  use  of  the  X-ray. 


a.  Polymorphonuclear  neutrophilea  some  showing  vacuoles  of  dege. 
eration  (compare  Fig.  15).     6.  Neutrophilic  myelocyte,     c.  Large  mono- 
nuclears with  basophilic  protoplasm  and  numerous  neutrophilic  graules. 
d.  Large  homogeneous  mononuclears  with  neutrophilic  protoplasm  show- 
ing vacuoles,     e.  More  mature  lymphocyte. 

The  number  of  blood  platelets  has  diminished. 


68 


Plate  XXXI.     Fig.  52 


PLATE    XXXII 

MYELOGENOUS   LEUKEMIA 

Female,  23  years  old.  Has  looked  pale  for  past  three  and  one- 
half  years.  Increasing  enlargement  of  spleen  for  last  eighteen 
months.  At  present  there  is  decided  pallor.  Spleen  extends  1 1 
cm.  to  the  right  of  median  line.     No  glandular  swellings. 

Hemoglobin,  65  per  cent.;  red  cells,  3,200,000;  leucocytes, 
337,000  in  1  c.mm.  Differential  count:  Polymorphonuclear 
neutrophiles,  94,040,  or  27.9  per  cent.;  myelocytes,  195,930,  or 
58.10  per  cent.;  basophiles,  39,190,  or  11.7  per  cent.;  eosino- 
philes,  7,840,  or  2.3  per  cent. 

Diagnosis:  Myelogenous  Leukemia. 


69 


Figure  53. — Myelogenous  Leukemia.     Stained 
Film.     Magnification  750 

The  complex  composition  of  the  blood  seen  in 
Fig.  51  was  never  noted  during  the  entire  course  of 
this  case.  In  this  specimen  the  leukemic  change  is 
shown  by  immature  forms  of  myelocytes,  instead  of 
by  typical  eosinophiUc  and  neutrophihc  myelocytes. 
Formerly  the  case  would  have  been  called  a  myelogen- 
ous leukemia  with  lymphoid  condition  of  the  blood. 
The  white  corpuscles  are  noted  in  groups  of  twenty 
or  thirty  and  have  been  distorted  by  pressure. 

The  red  cells  show  no  particular  change. 


a.  Polymorphonuclear  neutrophiles.  b.  Eosinophiles.  c.  Basophilic 
myelocytes  and  basophiles.  d.  Mononuclears  with  more  or  loss  baso- 
philic protoplasm.  c.  Homogeneous  mononuclears  with  neutrophilic 
protoplasm.  /.  Mononuclears  with  basophilic  protoplasm  and  faini. 
neutrophilic  granulation. 

70 


Plate  XXXII.      Fig.  53 


Plate  XXXIII.     Fig.  54 


PLATE    XXXIII 


MYELOGENOUS    Li:UKEMIA 


The  same  ease  after  treatment  with  arsenic  and 
X-ray. 

Hemoglobin,  90  per  cent. ;  red  cells,  4,050,000 ;  leucocytes, 
14,000  in  1  c.mm.  Differential  count:  Polymorphonuclear 
neutrophiles,  9,520,  or  68  per  cent.;  myelocytes,  1,820,  or  13 
per  cent.;  basophiles,  1,260,  or  9  per  cent.;  eosinophiles,  420  or 
3  per  cent. ;  lymphocytes,  980,  or  7  per  cent. 


u.  Polymorphonuclear  neutrophiles.  6.  Basophiles.  c.  Homogeneous 
mononuclears  with  basophilic  protoplasm,  d.  Mononuclears  with  baso- 
philic protoplasm  showing  neutrophilic  granulation. 

71 


Figure  54. — Myelogenous  Leukemia.     Stained 
Film.     Magnification  750 

The  condition  of  the  blood  shows  decided  improve- 
ment, and  considerable  search  is  necessary  before 
two  bone  marrow  cells  are  found  in  the  same  field, 
as  in  the  illustration.  Owing  to  the  persistent  high 
percentage  of  myelocytes  the  present  condition  must 
be  considered  a  remission  rather  than  a  cure.  The 
bone  marrow  cells  present  show  no  new  types. 

The  red  corpuscles  show  moderately  diminished 
hemoglobin  content.  Some  of  the  blood  platelets  are 
very  large. 


72 


I 


PLATE    XXXIV 

MYELOGENOUS   LEUKEMIA 

Male,  62  years  old.  Suffering  for  the  past  six  months  from 
general  weakness  and  emaciation,  with  enlargement  of  the  abdo- 
men. Moderately  anemic  and  cachectic.  No  glandular  swellings. 
The  spleen  extends  to  the  median  line.  Blood  appears  concen- 
trated. Hemoglobin,  105  per  cent.;  red  cells,  5,000,000;  leuco- 
cytes, 55,200  in  1  c.mm.  Blood  platelets  much  increased.  Dif- 
ferential count:  Polymorphonuclear  neutrophiles,  38,580,  or 
69.88  per  cent.;  lymphocytes,  7,700,  or  13.98  per  cent.;  transi- 
tionals,  390,  or  0.71  per  cent.;  eosinophiles,  580,  or  1.05  per 
cent.;  basophiles,  580,  or  1.05  per  cent.;  myelocytes,  7,350,  or 
13.33  per  cent. 

Numerous  normoblasts,  poikilocytes,  polychromatophilia  and 
basophilic  granulation  of  red  cells. 

Diagnosis:    Myelogenous  Leukemia. 


Figure  55. — Myelogenous  Leukemia.     Stained 
Film.    Magnification  750 

During  the  course  of  the  disease  this  case  con- 
stantly presented  a  condition  of  the  blood  known  as 
"mixed  cell  leukemia."  There  is  no  valid  reason  for 
retaining  the  term  in  this  case,  or  in  the  one  described 
in  connection  with  Fig.  53.  In  addition  to  neutro- 
philic myelocytes,  there  are  cells  representing  earlier 
stages  of  development  of  this  type,  namely,  mono- 
nuclears with  basophilic,  homogeneous  or  granular 
protoplasm. 

This  illustration  and  Fig.  53  show  that  all  the 
forms  of  bone  marrow  cells  need  not  necessarily  be 
present  in  every  case  of  myelogenous  leukemia. 
Many  specimens  were  examined,  and  not  a  single 

73 


eosinophilic  myelocyte  found.  As  these  cells  develop 
from  the  basophihc  myelocytes,  it  was  not  surprising 
to  find  comparatively  few  basophihc  myelocytes  and 
basophiles. 

Subsequent  developments  in  this  case  could  not  be 
followed,  as  the  patient  returned  to  his  home. 


a.  Polymorphonuclear  neutrophile.  6.  Immature  lymphocyte,  o. 
Neutrophilic  myelocytes,  d.  Mononuclears  with  more  or  lesa  marked 
jrianular  protoplasm,  e.  Large  mononuclears  with  homogeneous  baso- 
pliilic  protoplasm,     f.  Normoblast. 

Red  cells  show  no  essential  change.  Blood  plate- 
lets are  increased. 


74 


Plate  XXXIV.     Fig.  55 


PLATE    XXXV 

MYELOGENOUS   LEUKEMIA 

Female,  53  years  old.  Confined  to  bed  for  past  six  months. 
Extreme  pallor  and  prostration.  Spleen  extends  to  right  inguinal 
fold. 

Hemoglobin,  .35  per  cent.;  red  cells,  1,843,000;  leucocytes, 
158,000,  of  which  108,000,  or  68.3  per  cent,  are  myelocytes. 

Many  nucleated  red  cells,  basophilic  granulation,  polychro- 
matophilia   and   poikilocytosis. 

Diagnosis:    Myelogenous  Leukemia. 

Figure  56. — Myelogenous  Leukemia.     Stained 
Film.     Magnification  750 

While  the  manifold  cellular  types  in  this  picture 
resemble  those  in  Fig.  51,  closer  study  will  show  that 
they  are  quite  dissimilar.  The  noteworthy  feature 
is  the  presence  of  numerous  bone  marrow  cells  in 
various  stages  of  development.  The  relative  number 
of  these  cells  is  also  greater  than  in  the  other  cases 
illustrated,  and  probably  due  to  the  severity  of  the 
case  and  the  absence  of  complicating  lesions. 


75 


o.  Polymorphonuclear  neutrophiles.  h.  Eosinophilic  myelocytes  with 
nuclei  poor  in  chromatin  on  which  granules  are  also  seen.  c.  Basophilic 
myelocytes  varying  in  size  with  indented  nuclei  and  some  with  densely 
granular  protoplasm,  d.  Mononuclears  witli  basophilic  protoplasm  and 
basophilic  rather  than  neutrophilic  granulations,  e.  Large  mononuclears 
with  basophilic  homogeneous  cell  body.  /.  Smaller  cells  presumably 
leading  to  the  development  of  Ijonphocytes.  g.  Early  stages  of  transi- 
tionals.  h.  Large  mononuclears  with  neutrophilic  and  slightly  granular 
protoplasm,  i.  Undeveloped  cell  with  more  advanced  development  of  the 
protoplasm  than  the  following,  k.  Parent  cell.  A  large  mononuclear 
witli  pale  homogeneous  protoplasm.  I.  Megaloblast,  showing  mitosis, 
tlie  protoplasm  with  basophilic  granulation,  to.  Normoblast  in  the  same 
condition. 

Comparing  this  picture  with  Plate  I  will  show  the 
relative  stage  of  development  of  the  different  cells. 

The  red  cells  show  evidences  of  considerable 
anemia. 


76 


Plate  XXXV.     Fig.  56 


Plate  XXXVI.     Fig.  57 


PLATE    XXXVI 


ACUTE   LEUKEMIA 


The  clinical  picture  of  these  cases  is  characterized 
by  high  temperature  and  a  hemorrhagic  diathesis, 
frequently  combined  with  ulcerative  conditions  in 
the  mouth  and  throat,  and  local  glandular  sweUing. 
The  spleen  is  only  moderately  enlarged.  The  onset 
is  acute  and  the  general  impression  is  that  of  an 
exceedingly  severe  infectious  disease.  A  profound 
anemia  develops  rapidly  and  the  cases  invariably 
terminate  fatally  in  a  few  days,  or  at  most  several 
weeks.  An  examination  of  the  blood  is  necessary 
for  positive  diagnosis. 

Recent  observations  indicate  that  a  condition  of 
the  blood  characteristic  of  chronic  lymphatic  leukemia 
or  of  myelogenous  leukemia  may  also  be  found  in 
acute  leukemia.  While  the  changes  in  the  blood 
may  vary  in  the  different  cases,  usually  in  acute 
leukemia  an  enormous  number  of  immature  bone 
marrow  cells  are  found,  the  normal  metamorphosis 
into  more  mature  forms  being  absent.  The  modern 
view  is  justified  that  the  severely  acute  character  of 
the  disease  with  leukemic  changes  in  the  blood  of 
one  or  other  type  is  pathognomonic  of  acute  leuke- 
mia, the  disease  not  necessarily  demanding  a  specific 
blood  picture.  The  cause  of  this  rapidly  fatal  disease 
is  unknown,  but  it  would  seem  that  the  extensive 
ulcerations  in  the  naso-pharynx  usually  present  may 
have  etiological  significance. 


Boy,  1 1  years  old.  Acute  onset  with  chills  and  uncontrollable 
epistaxis.  Course  of  the  disease  characterized  by  high  tempera- 
ture, hemorrhagic  diathesis,  profound  anemia,  glandular  swell- 

77 


ings  in  the  neck  and  secondary  sepsis  due  to  ulcerations  in  the 
naso-pharynx.     Death  at  the  end  of  three  weeks. 

Blood  decidedly  hydremic.  Hemoglobin,  25  to  22  per  cent. ; 
red  cells,  1,068,000  to  736,000  in  1  c.mm. ;  leucocytes,  28,300  to 
11,600  in  1  c.mm.  Differential  count:  Polymorphonuclear  neu- 
trophiles,  3.2  per  cent.,  or  900;  abnormal  leucocytes,  96.8  per 
cent.,  or  27,400.  No  other  varieties  of  leucocytes  present.  As 
the  result  of  the  secondary  septic  condition  the  total  leucocyte 
count  fell  to  1 1 ,600,  the  polynuclear  neutrophiles  increased  to 
8.5  per  cent.,  or  2,180,  and  the  abnormal  leucocytes  decreased 
to  91.7  per  cent.,  or  10,600.  This  effect  of  a  septic  complication 
in  leukemia  has  frequently  been  noted. 

Diagnosis:    Acute  Leukemia.     Sepsis. 

Figure  57. — Acute  Leukemia.     Stained  Film. 
Magnification  750 

The  red  corpuscles  show  all  the  usual  evidences 
of  a  pernicious  anemia,  as  follows:  Decided  pallor, 
microcytes,  macrocytes,  megaloblasts,  poikilocytosis, 
polychromatophilia,  and  basophilic  granulation.  The 
decided  diminution  in  the  number  of  red  cells  is  also 
apparent  in  the  picture. 

The  abnormal  leucocytes  apparently  belong  to  one 
cell  tj'pe,  but  show  different  stages  of  development. 
Neutrophilic  and  occasionally  eosinophilic  myelo- 
cytes are  also  found.  The  abnormal  cells  mentioned 
all  show  more  or  less  lobulated  nuclei  poor  in  chro- 
matin. They  have  a  shghtly  basophilic  and  rarely 
neutrophihc  protopla.sm,  and  many  show  a  variously 
dense  fine  neutrophihc  granulation.  Vacuoles  are 
sometimes  observed. 

These  cells  are  identified  as  immature  bone 
marrow  cells,  but  as  they  are  granular,  they  have 
attained  a  definite  stage  of  development  ( see  Plate  I ) . 
The  nuclei  are  decidedly  indented  or  lobulated,  and 
amitotic  division  figures  in  cells  with  a  larger  amount 
of  protoplasm  are  frequently  observed. 

A  certain  morphological  change  is  always  observed 
in  these  leucocytes,  the  significance  of  which  is  still 
obscure.     A  large  number  of  the  cells  show  proto- 

78 


plasmic  processes  of  diit'erent  kinds.  In  some  a 
wreath  of  short  threads  surrounds  the  cell,  while 
others  show  one  or  more  club-shaped  projections. 
It  would  seem  that  these  are  particles  of  protoplasm 
amputated  from  tlie  cell  by  constrictions,  and  par- 
tially destroyed  by  fixation  of  the  specimen  (see 
Fig.  58). 


a.    Polymorplionuck'iir    neutropliile.      h.    Lymphocyte,      c.    Immature 
bone  marrow  cells,     d.  Neutrophilic  myelocyte,     e.  Megaloblast. 


79 


PLATE    XXXVII 

Figure  58. — Acute  Leukemia.     Fresh  Double 
Cover-glass  Specimen.     Magnification  750 

[The  same  case.] 

Gentian  violet  has  been  added  to  the  diluting  fluid. 

Immediately  after  the  preparation  of  the  specimen, 
a  considerable  number  of  all  the  leucocytes  show 
certain  globular  jjrocesses  as  seen  in  the  illustration. 
Several  cyst-like  structures  appear  attached  to  the 
cell,  some  being  twice  or  three  times  as  large  as  the 
actual  cell  body,  the  protoplasm  of  which  is  much 
diminished  in  proportion  to  the  nucleus.  The 
granulations  are  never  found  in  the  processes,  but 
remain  in  what  is  left  of  the  cell  body- 


80 


Plate  XXXVU.     Fig.  58 


Plate  XXXVIII.     Fig.  59 


PLATE    XXXVIII 

BLOOD    CHANGES    ASSOCIATED    WITH    TUMORS    OF    THE 
BONE   MARROW 

At  different  stages  of  development  certain  tumors 
give  rise  to  metastases  in  the  bone  marrow,  with 
resulting  changes  in  the  morphological  composition 
of  the  blood. 

In  circumscribed  metastases,  there  is  only  an 
irritation  of  the  adjacent  bone  marrow,  the  degree 
of  which  depends  on  the  extent  of  the  involvement. 
The  peripheral  blood  showS[  evidence  of  increased 
or  hurried  regeneration,  due  to  the  increased  com- 
pensating function  of  the  remaining  healthy  marrow. 

In  other  cases,  there  is  a  diffuse  distribution  of  the 
metastatic  process  in  the  bone  marrow,  and  in  con- 
sequence the  latter  is  largely  replaced  by  tumor 
tissue.  Under  these  circumstances  the  peripheral 
blood  not  only  contains  bone-marrow  cells,  but  also 
shows  a  number  of  cellular  varieties  which  justify 
conclusions  in  regard  to  the  character  and  extent  of 
the  lesion.  The  red  cells  also  undergo  a  more  or 
less  serious  change  and  frequently  show  evidences 
resembling  those  of  grave  pernicious  anemia. 

Carcinoma  of  the  Bone  Marrow 

Male,  33  years  old.  Pain  in  the  left  side  after  over-exertion  in 
lifting  a  machine.  One  month  later  neuralgic  pains  also  noted  on 
the  right  side  and  in  lumbar  region.     Progressive  pallor. 

Clinical  examination:  A  chain  of  small  hard  glands  palpable 
on  the  right  side  of  the  neck.  Rapid  development  of  bilateral 
choked  disk.  Pleural  exudate  on  left  side.  Large  epitlieloid 
cells  found  in  pleural  and  lumbar  fluid.  Sternum  painful  on 
pressure.     Progressive  anemia.     Died  at  the  end  of  ten  weeks. 

Autopsy:    Flat  cancer  of  stomach  a  little  smaller  than  tlie  size 

81 


of  a  silver  dollar,  apparently   quiescent.     Numerous   metastases 
in  the  bones  (skull,  ribs,  vertebrae  and  pelvis). 

Blood  examination  day  before  death:  Hemoglobin,  lO  per 
cent.;  red  cells,  1,984,000 ;  leucocytes,  16,400.  Differential 
count:  Polymorphonuclear  neutrophiles,  13,440,  or  82.0  per  cent.; 
lymphocytes,  1,340,  or  8.2  per  cent.;  transitionals,  470,  or  2.9 
per  cent.;  eosinophiles,  201,  or  1.2  per  cent.;  myelocytes,  135, 
or  0.7  per  cent.;  "abnormal  cells"  (tumor  cells.'')  806,  or  4.9 
per  cent.  In  counting  500  leucocytes,  1 20  nucleated  red  cells  are 
seen,  of  which  a  moderate  number  are  megaloblasts. 


Figure  59. — Carcinoma  of  Bone  Marrow. 
Film.    Magnification  330 


St 


ainec 


In  addition  to  a  neutrophilic  leucocytosis  marked 
changes  are  present  in  the  red  cells,  i.  e.,  deficient 


A.  Normoblaata.  6.  Mepaloblast.  c.  Normoblasts  with  polychroma- 
tophilia.  rf.  Normoblasts  showinj^  amitotic  division,  e.  Polymorphonu- 
clear neutrophiles.  /.  Lymphocytes,  g.  Myelocyte,  h.  Abnormal  cells 
(Tumor  cells?). 

82 


hemoglobin,  polychroinatophilia,   poikilocytosis,   and 
nucleated  cells. 

While  some  of  these  changes  are  referable  to  the 
secondary  anemia,  the  presence  of  an  unusual  num- 
ber of  nucleated  red  cells  is  doubtless  due  to  severe 
irritation  of  the  bone  marrow  by  the  metastatic 
growth.  The  presence  of  munerous  myelocytes  in 
the  peripheral  circulation  can  be  ascribed  to  the  same 
cause,  as  these  cells  never  occur  in  such  numbers,  and 
are  frequently  entirely  absent  in  cases  of  secondary 
or  primary  anemia.  It  is,  therefore,  reasonable  to 
mfer  that  the  existing  abnormal  composition  of  the 
blood  is  referable  to  the  active  compensating  func- 
tion of  the  remaining  normal  bone  marrow,  and  due 
to  direct  irritation  of  this  medullary  tissue  by  the 
metastatic  lesion. 


88 


PLATE    XXXIX 

SARCOMA  OF  THE  BONE   MAEROW 

Female,  57  years  old.  Sarcoma  of  the  naso-pharynx,  with  in- 
volvement of  the  local  glands,  and  extension  of  the  tumor  to  the 
base  of  the  skull  and  the  cranial  cavity.  In  the  early  stages  the 
case  was  supposedly  a  pseudo-leukemia.  Secondary  diffuse  sar- 
comatosis  of  bone  marrow.     Death. 

Blood  examination:  Fully  a  year  before  the  patient's  death, 
certain  changes  in  the  blood,  such  as  poikilocytosis,  polychroma- 
tophilia,  basophilic  granulation,  and  the  presence  of  normoblasis 
justified  a  suspicion  of  the  participation  of  the  bone  marrow  in 
the  disease,  and  led  to  a  characteristic  blood  picture  which  per- 
sisted for  several  months  until  the  patient's  death.  Early  in  the 
disease  the  condition  was  as  follows :  Hemoglobin,  60  per  cent. ; 
red  cells,  3,104,000;  leucocytes,  3,600  in  1  c.mm.  Normal  dif- 
ferential count.  This  was  followed  by  progressive  anemia,  the 
appearance  of  megalocytes  and  many  normoblasts,  and  cells  of 
the  IjTnphocyte  type  having  larger  or  smaller  round  or  indented 
nuclei,  with  more  or  less  chromatin,  and  with  but  a  narrow  rim  of 
protoplasm  if  any.  These  cells  differed  from  the  normal  lympho- 
cyte, and  from  the  cell  seen  in  chronic  lymphatic  leukemia,  and 
closely  resembled  the  type  of  which  the  tumor  was  composed. 
The  inference  seems  reasonable  that  these  were  sarcoma  cells 
■which  had  entered  the  circulation. 

At  the  height  of  the  disease,  eight  weeks  before  the  patient's 
death,  the  blood  was  as  follows :  Hemoglobin,  40  per  cent. ;  red 
cells,  2,608,000;  leucocytes,  7,000  in  1  c.mm.  Differential  count: 
Polymorphonuclear  neutrophiles,  2,300,  or  32.85  per  cent.;  lym- 
phocytes, 800,  or  11.42  per  cent.;  transitionals,  60,  or  0.86  per 
cent. ;  myelocytes,  40,  or  0.57  per  cent. ;  tumor  cells,  3,800,  or 
54.3  per  cent. 


84 


Plate  XXXIX.     Fig.  60 


Figure  60. — Sarcoma  of  Bone  Marrow. 
Film.    Magnification  750 


Stained 


Composite  picture.  The  majority  of  tumor  cells 
had  the  appearance  of  (c)  in  the  illustration,  with 
large  and  frequently  lobular  nuclei,  containing  more 
or  less  chromatin  and  surrounded  by  a  narrow  rim 
of  protoplasm.  Abnormally  large  cells  having  large 
^'esiculated  or  multilobular  nuclei  were  also  present 
as  shown   {d). 


a.  Myelocytes. 
Me^loblaat. 


!>.  Lfcrge  ly«pk««yte«.     •   »*i  d.     Tuiii»r  cells,     e. 


86 


PLATE    XL 


LEUKOSARCOMATOSIS 


Sternberg  recently  applied  this  name  to  a  clinical 
condition,  which  will  demand  further  observation 
for  accurate  definition.  The  cases  may  closely 
resemble  those  of  acute  leukemia,  in  the  sudden 
development  of  severe  constitutional  disturbances 
with  high  temperatures  and  a  hemorrhagic  diathesis, 
resulting  fatally  in  a  few  days. 

Concerning  the  gross  pathology,  a  tumor  is  found 
in  some  portion  of  the  body  which  has  the  macro- 
scopic appearance  of  a  lymphosarcoma  {Kundrat), 
or  there  are  changes  in  portions  of  the  lymphatic 
system  having  the  appearance  of  pseudoplasm. 

The  condition  of  the  blood  also  closely  resembles 
that  usually  found  in  acute  leukemia,  showing  im- 
mense numbers  of  large  mononuclear  or  multilobular 
abnormal  cells,  the  average  count  of  which  exceeds 
500,000  in  1  c.mm.  These  cells  represent  an  atypical 
pathological  type,  which  should  probably  not  be  con- 
sidered as  a  preliminary  stage  of  the  myelocyte,  but 
rather  as  a  "tumor  cell,"  it  being  identical  with  the 
cell  found  in  the  neoplasm  present,  or  in  the  tumor- 
hke  changes  of  the  lymphatic  system. 

Boy,  13  years  old.  Has  looked  poorly  and  anemic  for  a  con- 
siderable time.  The  illnes.s  began  witli  pain  and  swelling  in  the 
throat,  fever  and  marked  prostration.  On  admission  to  the  hos- 
pital the  patient's  condition  was  critical.  He  presented  numer- 
ous ulcerations  of  the  gums,  and  nuilti])le  cutaneous  hemorrhages 
about  the  size  of  a  quarter,  all  over  the  body  and  particularly 
on  the  face,  some  of  which  were  covered  with  scabs.  The  spleen 
wa.s  undoubtedly  enlarged.     Death  six  hours  after  admission. 

Blood  examination:  Moderate  anemia.  Leucocytes,  560,000  in 
1  c.mm. 

86 


Plate  XL.     Fig.  61 


Autopsy :  The  entire  mucosa  of  the  middle  and  lower  ileum  was 
covered  with  tumors  the  size  of  a  hazelnut  or  a  walnut,  resembling 
sarcomata,  and  projecting  into  the  lumen  of  the  bowel.  Hyper- 
trophy of  the  lymphatic  apparatus  of  the  bowel,  and  of  that  at 
the  base  of  the  tongue.  The  bone  marrow  was  grayish-red  in 
color. 

Figure  61. — Leukosarcomatosis.     Stained  Film. 
Magnification  750 

A  certain  uniformity  in  the  cellular  types  charac- 
terizes the  specimen.  Unsuitably  or  imperfectly 
stained  fihiis  show  nothing  beyond  many  cells  of 
similar  appearance  and  lymphoid  type.  In  good 
specimens,  however,  certain  variations  in  size,  con- 
figuration of  nuclei  and  character  of  protoplasm  can 
be  made  out  in  the  cells.  They  all  have  round,  more 
or  less  lobulated  nuclei,  often  vesiculated  in  appear- 
ance, and  very  poor  in  chromatin.  Several  nucleoli 
are  not  vmcommon.  Occasionally  the  nucleus  is 
indistinct  and  so  poor  in  chromatin  that  its  outhne 
cannot  be  made  out.  The  nuclei  of  the  smaller  cells 
show  a  denser  structure  and  a  greater  amount  of 
chromatin.  The  protoplasm  is  always  scanty  and 
often  shows  as  a  narrow  margin,  very  few  cells  having 
shght  neutrophihc  granulation. 

The  conspicuous  fragmentation  of  the  nuclei  is 
possibly  a  sign  of  pathologically  rapid  growth  of 
these  cells.  A  certain  resemblance  between  these 
cells  with  granulation,  and  the  leucocytes  seen  in 
acute  leukemia  cannot  be  denied.  As  these  cells  are, 
however,  identical  with  those  which  constitute  the 
primary  tumor,  they  must  be  considered  tumor  cells 
and  not  bone  marrow  cells. 

The  red  cells  in  the  stained  film  show  no  essential 
anemic  changes. 

An  eosinophilic  myelocyte  is  seen  below  to  the 
right,  and  several  others  were  found,  but  with  this 
exception  no  other  additional  or  pathological  blood 
cells  could  be  found  in  the  entire  specimen. 

07 


PLATE    XLI 

BLOOD    PARASITES 
MALARIAI.   PARASITES    AND   TRYPANOSOMES 

Tertian  Malaria 

Figure  62. — Endogenous  Development  of  Tertian 
Parasite.     Magnification  750 

Very  young  parasites,  just  after  entering  the  red 
cell,  present  a  hyaline  form.  In  the  stained  specimen 
a  distinct  ring  form  is  seen,  the  brilliant  red  chro- 
matin appearing  at  one  pole,  with  the  so-called  polar 
swelling  directly  opposite.  These  small  tertian  rings 
are  not  all  equally  distinct.  Further  development 
produces  the  "large  tertian  rings,"  particularly  by 
growth  of  the  polar  swelling.  Continued  growth 
and  irregular  changes  in  form  result  in  grotesque 
figures.  The  parasites  are  now  approximately  24 
hours  old.  An  increase  in  the  amount  of  chromatin, 
and  the  deposit  of  yellowish-black  pigment  are  in- 
variably observed  at  this  period,  and  the  red  cor- 
puscle, having  increased  to  nearly  or  quite  double 
its  original  size,  is  pale  in  color.  Later  the  parasites 
appear  as  flattened  structures,  with  chromatin  nuclei 
often  regularly  arranged  and  surrounded  by  an 
achromatic  zone.  The  chromatin  nuclei  increase  in 
number,  the  pigment  collects  in  a  central  mass  or 
strand,  and  the  development  of  the  parasite  is  com- 
plete shortly  before  the  febrile  attack.  It  now  pre- 
sents the  chromatin  granules,  each  surrounded  by  a 
blue  ring,  and  the  whole  appearing  as  a  regular  group 
which  constitutes  the  sporulation  form.  This  now 
bursts  and  the  young  sporozoids  are  free  to  enter 

88 


other  red  cells  to  begin  another  48-hour  period  of 
development. 

Figure  63. — Endogenous  Development  of  Quartan 
Parasite.     Magnification  750 

The  life  history  is  very  similar  to  that  of  the  tertian 
parasite,  but  72  hours  are  required  for  the  develop- 
ment of  this  form.    During  the  first  day  the  quartan 
cannot   be   distinguished   from  the  tertian   parasite, 
but  later  it  is  characterized  by  an  absence  of  increase 
in  size  of  the  affected  red  cell,  probably  due  to  the 
smaller  size  of  the  parasite.      Subsequent  develop- 
ment  usually    shows    a   band-like    structm-e    with    a 
large  amount  of  pigment  instead  of  the  grotesque 
forms  of  the  tertian  with  less  pigment.     The  mature 
parasite  has  a  smaller  number  of  chromatin  nuclei, 
and  the  sporulation  form  shows  ten  or  twelve  seg- 
ments   only,    often    in    "sun-flower"    arrangement. 
The  small  size  of  the  quartan  parasite,  as  compared 
with    the    tertian, .  is    particularly    apparent    in    the 
sporulation  stage. 

In  tertian  as  well  as  quartan  malaria,  adult  para- 
sites are  observed  in  the  blood,  which  do  not  resemble 
the  ordinary  forms.  Some  have  much  chromatin 
and  a  wealdy  stained  protoplasm,  these  being  the 
male  gametes.  Others  have  a  small  amount  of 
chromatin  and  a  deeply  stained  protoplasm  and  are 
the  female  gametes.  The  sexual  development  of 
the  parasites  begins  with  these  forms. 

Figure  64. — Endogenous  Development  of  Estivo- 
Autumnal  Parasite.     Magnification  750 

The  endogenous  development  of  this  parasite  is 
not  perfectly  understood  as  yet.  In  the  early  ring 
stage  the  parasites  are  smaller  and  more  dehcate 
than  the  tertian  or  quartan,  but  later  cannot  be 
distinguished  from  the  latter  of  the  same  size.  Cres- 
cents represent  the  last  stage  in  the  development  of 

89 


the  estivo-autumnal  parasite  and  change  into  oval 
or  round  bodies.  The  crescents  are  characteristic 
of  estivo-autumnal  malaria  and  are  found  during 
the  febrile  attacks  as  well  as  in  the  intervening 
quiescent  periods,  whereas  the  ring  form  is  found  in 
the  febrile  stage  only.  The  crescents  also  develop 
in  the  red  cells  and  are  often  seen  surrounded  by  a 
halo  of  hemoglobin  representing  the  remnant  of  the 
erythroc}i:e.  In  other  crescents  the  shell  of  the  red 
corpuscle  is  drawn  hke  a  thread  between  the  poles 
of  the  parasite,  giving  rise  to  basket-shaped  figures. 
Both  poles  of  all  crescents  are  more  deeply  stained 
than  the  center,  which  contains  chromatin  and  pig- 
ment. The  gametes,  or  forms  for  the  sexual  develop- 
ment, are  derived  from  the  crescents  and  have  the 
same  characteristics  as  those  of  tertian  or  quartan 
malaria. 


90 


Plate  XLI.     Fig..  62,  63,  64 


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62 


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63 

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Plate  XLII.     Figs.  65,  66 


PLATE    XLII 

PARASITES   OF   TERTIAN    MALARIA 


"•  III 


Male,  28  years  old.     Had  malaria  in  Algiers  while  servin 
the   army.      Develops   a   relapse   after  his   return   home.      Many 
tertian  parasites  are  found  in  tlie  blood. 

Diagnosis:   Tertian  Malaria. 

Figure  65. — Tertian  Malaria.     Fresh  Double 
Cover-glass  Specimen 

The  recognition  of  the  malarial  parasite  is  more 
difficult  in  fresh  blood  than  in  the  stained  film. 
Rings  and  young  parasites  with  but  httle  pigment 
may  escape  attention,  though  the  mature  ones  should 
be  easily  seen  on  account  of  the  active  flowing  and 
circulating  motion  of  their  brownish-black  pigment. 

A  visible  enlargement  of  the  red  cells  containing 
the  parasites  in  any  stage  cannot  be  made  out.  The 
parasite  usually  occupies  the  center  of  the  red  cell 
and  abstracts  its  hemoglobin,  which  is  converted  into 
melanin,  thus  accounting  for  the  pallor  of  the  cor- 
puscle. In  the  sporulation  forms,  which  are  rarely 
seen,  the  pigment  lies  in  the  center  of  the  occasionally 
rosette-shaped  parasite. 

Two  adult  parasites  and  one  sporulation  form  are 
seen  in  the  illustration,  and  are  easily  differentiated 
from  the  leucocyte  in  the  center. 

Male,  20  years  old.  Has  always  been  well  and  never  away 
from  home.  Develops  chills  some  time  after  having  been 
severely  bitten  by  mosquitoes.  The  town  in  which  patient  lived 
contains  many   Italians  who  arrive  from  home  each  spring. 

The  blood  film  shows  a  moderate  number  of  tertian  parasites. 

Diagnosis:    Tertian  Malaria. 

91 


Figure  66. — Tertian  Malaria.     Stained  Film. 
Magnification  750 

The  specimen,  obtained  during  the  chill,  shows  a 
young  tertian  ring  and  a  mature  sporulation  form. 
The  ring,  which  shows  two  lateral  indurations  in- 
stead of  a  polar  swelling,  is  about  to  enter  the  red 
corpuscle. 

The  sporulation  form  still  lies  within  the  pale, 
scarcely  visible  erythrocyte.  The  somewhat  regular 
arrangement  of  the  youthful  forms  is  evident,  each 
chromatin  nucleus  being  surrounded  by  a  hght 
achromatic  zone  beheved  to  be  nuclear  juice.  The 
pigment  is  seen  as  a  slender  strand. 

In  view  of  the  recent  and  moderately  severe  infec- 
tion, the  red  cells  show  no  anemic  changes. 


i 


92 


PLATE    XLIII 

Schoolboy,  15  years  old.  Develops  chills  on  his  return  from 
Italy.  Duration  of  illness,  six  days.  Numerous  tertian  para- 
sites in  blood  specimen. 

Diagnosis:    Tertian  Malaria. 

Figure  67. — Tertian  Malaria.     Stained  Specimen. 
Magnification  750 

The  specimen  was  obtained  a  few  hours  before 
the  febrile  attack,  and  shows  tertian  parasites  in 
various  stages  of  development.  After  a  number  of 
attacks  have  occurred,  the  cases  show  so-called 
"sterile  forms;"  parasites  which  do  not  develop 
beyond  a  certain  stage.  If  two  distinct  generations 
of  parasites,  maturing  at  different  periods,  are  present 
in  the  blood,  they  give  rise  to  the  quotidian  type  of 
the  disease,  and  present  a  correspondingly  complex 
picture. 

The  ring  forms  and  the  mature  parasites  shown 
in  the  illustration  contain  considerable  pigment  and 
but  httle  chromatin.  The  dehcate  red  and  black 
granulation  in  the  red-cell  host  is  noteworthy,  and 
since  it  has  been  observed  with  the  tertian  parasite 
only,  may  be  characteristic  of  this  form. 

Sailor,  26  years  old.  Has  had  malarial  attacks  for  a  period  of 
eight  weeks.  No  quinine  administered.  Decided  anemia.  Large 
spleen.  Fever  of  the  quotidian  type.  Numerous  tertian  parasites 
in  the  blood  specimen. 

Diagnosis:  Tertian  Malaria   (Quotidian). 

9.3 


Figure  68. — Tertian  Malaria.     Stained  Film. 
Magnification  750 

The  specimen  contains  a  large  number  of  para- 
sites, and  red  cells  are  seen  into  which  several  ring 
forms  have  penetrated.  This  is  beheved  to  be  in- 
dicative of  the  estivo-autumnal  type,  but  the  type  of 
the  fever,  the  presence  of  many  mature  parasites,  and 
the  shght  granulation  of  the  affected  erythrocytes 
would  indicate  the  tertian  type. 

The  red  cells  show  shght  anemic  changes. 


94 


I 


Plate  XLIII.     Figs.  67,  68 


Plate  XLIV.     Figs.  69,  70 


PLATE    XLIV 

Figure  69.— Quartan  Malarigi.     Stained  Film. 
Magnification  750 

Three  malarial  parasites  are  seen  in  the  field.  The 
upper  one  consists  of  a  narrow  band  passing  through 
the  red  cell.  There  is  a  fine  line  of  chromatin 
granules  lying  beside  the  body  of  the  parasite,  which 
is  stained  blue.  A  more  mature  quartan  is  seen  on 
the  left,  in  the  form  of  a  broad  band  with  consider- 
able pigment  and  beginning  increase  of  chromatin. 
The  band  form  characterizes  the  quartan  parasite, 
and  in  the  more  mature  form  shown  in  the  lower 
part  of  the  field,  the  small  size,  the  shght  degree 
of  distortion,  and  the  small  number  of  chromatin 
granules  are  the  differential  points. 

Figure  70.— Estivo-Autumnal  Malaria.     Stained 
Film.    Magnification  750 

Two  delicate  rings  and  a  crescent  are  seen  in  the 
field.  In  recent  infections,  and  after  repeated  re- 
lapses, both  rings  and  crescents  are  invariably  found 
in  the  peripheral  blood.  In  chronic  malaria  crescents 
are  frequently  present  in  considerable  numbers,  but 
the  ring  form  is  not  found.  In  cases  of  malarial 
cachexia  it  may  be  impossible  to  find  parasites. 

The  small  rings  are  more  dehcate  in  structure  than 
the  broader  ones  of  tertian  or  quartan  cases.  The 
crescents  show  distinct  polar  stain,  considerable  pig- 
ment, and  are  surrounded  by  the  basket-shaped  out- 
line of  the  red  ceU,  exceeding  in  size  the  diameter  of 
the  erythrocyte. 


95 


PLATE    XLV 


TEYPANOSOMIASIS 


Human  trypanosomiasis  is  due  to  parasites  of  the 
blood  called  trypanosomes,  which  belong  to  the 
flagellated  protozoa.  The  parasites  are  actively 
motile  in  fresh  blood  and  show  the  following  char- 
acteristics in  the  stained  film:  They  are  fish-shaped 
and  very  slender,  two  or  three  times  as  long  as  the 
diameter  of  a  red  cell,  with  a  long  flagellum  at  the 
anterior  extremity,  and  an  undulating  membrane 
on  one  side.  A  rather  large  nucleus  with  chromatin 
tint  is  found  in  the  center.  A  bright  red  granule, 
the  centrosome,  is  seen  near  the  posterior  blunt  end, 
from  which  a  fine  line  of  red  chromatin  extends  along 
the  margin  of  the  undulating  membrane,  into  the 
flagellum.  The  body  of  the  trypanosome  takes  a 
blue  plasma  stain.  These  parasites  live  in  the 
plasma  and  not  in  the  corpuscles  of  the  blood,  and 
multiply  by  longitudinal  fission. 

Trypanosomiasis  may  take  an  acute  or  chronic 
course,  the  symptoms  consisting  of  an  irregular 
fever,  anemia,  emaciation,  enlargement  of  the  spleen 
and  glandular  swelhngs.  The  parasites  may  exist 
in  the  blood  of  man  for  years  without  giving  rise  to 
clinical  evidences.  In  most  cases  they  pass  from 
the  blood  into  the  cerebrospinal  fluid  and  occasion 
"sleeping  sickness,"  which  is  a  symptom  of  trypan- 
osomiasis. 

The  disease  is  communicated  to  man  by  a  fly 
(glossina  palpalis),  the  sting  introducing  the  parasite 
into  the  circulation.  It  is  possible  that  they  develop 
in  the  glossina,  or  they  may  imdergo  a  process  of 

96 


Plate  XLV.     Fig.  71 


development  similar  to  that  of  the  malarial  parasite 
in  the  anopheles. 

Figure  71. — Human  Tiypanosomiasis.      Stained 
Film.     Magnification  Approx.   1,000 

The  specimen,  which  was  obtained  from  a  Euro- 
pean, contains  but  few  trypanosomes.  The  lower 
parasite  in  the  illustration  shows  a  twisted  body,  the 
undulating  membrane  and  chromatin  thread,  which 
becomes  continuous  with  the  flagellum,  are  plainly 
visible.  The  protoplasm  of  both  parasites  shows  a 
shghtly  granular  appearance. 


97 


INDEX 


Achromatic  zone,    88 
Anemia,  52 

in  children,  43 

pernicious,  47,  50 

polychromatophilic,   37 

primary,  47 

secondary,  41 

secondary,  acute,  41 

secondary,  chronic,  42,  45 
Anopheles,  97 

Basophiles,  22,  24 

Blood  cells,  human,  12 
cells,  human,  transitional 
forms,  12 

Blood,  changes  in  tumors  of 
bone  marrow,  81 
corpuscles,  counting  of,  3 
development  of  red,  12 
development  of  white,  12 
examination  of    (technic),  1 
examination  of  fresh,  8 
normal,  15,  18 
normal  composition  of,  15 
normal  leucocytes  of,  19 
normal  rouleaux  formation,  16 
obtaining  of,  1 
parasites,  88 
platelets,  34,  35 
stain,  formula  of,  11 
Bone  marrow,  blood  changes  in 
tumors  of.  81 
carcinoma  of,  81 
sarcoma  of,  84 

Carcinoma  of  bone  marrow,  81 
Centrosome,  96 
Chlorosis,  48 
Chromatin  granules.  88 
Coloriraetric  determination,  2 
Corpuscles,  red,  34 

red  nucleated,  34 

white,  19 
Counting  chamber,  4,  9 


Diathesis,  hemorrhagic,  77 
Diluting  fluid,  3 
Diphtheria,  blood  changes  in. 


32 


Eosinophile,  13,  22,  24 
Erythroblast,  14,  34 

Karyolytic,   35 
Erythrocyte,  34 

crenated,  45 

polychromatophilic,  37 
Estivo-autumnal  parasite,  endoge- 
nous development  of,  89 

Films,  preparing  dried,  1 

staining  dried,  9 
Fleischl-Miescher  hemometer,  2 

Glossina  palpalis,  96 
Goicer's  hemoglobinometer,  2 
Granulation,  basophilic,  39 
Oraivitz,  14 

Bagedorn  needle,  1 
Hayem's  solution.  3 
Hemocytometer,  4 
Hemoglobin,  estimation  of  the 

amount  of,  2 
Hemoglobinometer,  2 
Hemometer,  2 

Irritation  form  of  Tiirck,  13 

Kundrat,  86 

Lead  poisoning,  39 
Leishman  modification.  9 
Leucocytes,  counting  the,  6 

differential  count  of,  7,  19 
Leucocytosis,  26,  32,  50 

eosinophilic,  28 

in  child,  30 

neutrophilic,  26,  29 
Leucopenia.  50 
Leucosarcomatosis,  86 
Leukemia,  52 

acute,  77 

lymphatic,  52 

lymphatic,  chronic,  56 

myelogenous,  52,  54,  62 
Lymphocytes,  12,  20,  25 

degeneration  forms  of,  25 
Lymphosarcoma,  86 

98 


Malaria,  crescents  in,  95 

estivo-autiimnal,  89,  95 

quartan,  89,  95 

rings  in,  95 

sterile  forms,  93 

tertian,  88,  91,  93 
Malarial  parasites,  88 
Megaloblast,   13,  35 
Microblast,  35 
Mitotic  division,  35 
Mixing  pipette,  4 
Myelocytes,   12 

Neutrophiles,  polymorphonuclear, 

19 
Newton's  rings,  5 
Normoblast,  13,  34 
Nuclear  division  figures,  35 

Panoptic  stain,  9 
Parasites,  malarial,  88 

of  blood,  88 
Pipette,  mixing,  4 
PoikilocytosiB,  50 
Polychromatophilia,  50 
Protoplasm,  basophilic,  12 

neutrophilic,   12 
Pseudoplasm,  86 

Quartan  parasites,  endogenoxis 
development  of,  89 


R«d  corpuscles,  counting  the,  4 
Romanowsky   method,  9 

Sahli  hemometer,  2 

Sarcoma  of  bone  marrow,  84 

Schmalz  method,   10 

Sleeping  sickness,  96 

Specific  gravity,  estimation  of,  10 

Sporozoids,  88 

Sporulation,  88 

Sternberg,    86 

Syphilis,  infantile  hereditary,  44 

Tertian  parasite,  endogenous 
development  of,  88 

rings,  88 
Thoma-Zeiss  hemocytometer,  4 
Toisson's  solution,  4 
Transitional  forms,  20,  24 
Trichinosis,  22 
Trypanosome,  88,  96 
Trypanosomiasis,   96 
"Tumor  cell,"  86 
Tiirck  chambers,  3 

irritation  forms,  23 

Weidenreich,    16 
Wright's  stain,  11 

Zappert  chambers,  3 


Date  Due 


D  000  164  456  5 


WH17 

SS^+lh 

1920 

Schleip,  Karl. 

Hematological  atlas  with  a 

description  of  the  technic 

of  blood  examination 

WH17 

SSUlh 

1920 

Schleip,  Karl. 

Hematological  atlas  with  a  description 
of  the  technic  of  blood  examination 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


